Статті в журналах з теми "American Association of University Women. Committee on Fellowships"

Sir William Osler’s legacy lives on through the Fellowship of Postgraduate Medicine (FPM). Osler was in 1911 founding President both of the Postgraduate Medical Association and on 1981 of the Inter-allied Fellowship of Medicine. These societies merged later in 1919, with Osler as President until his death at the end of that year. This joint organization was initially called the Fellowship of Medicine and Post-Graduate Medical Association and continues to this day as the Fellowship of Postgraduate Medicine. In the 1880s, in his role as medical leader in North America, Osler pioneered hospital residency programmes for junior trainee doctors. As Regius Professor of medicine in Oxford from 1905, Osler wished early postgraduate teaching in the UK, and in London in particular, to include access to ‘the wealth of material at all the hospitals’. He also saw medical societies as important for providing reliable continuous medical develop for senior doctors.Under Osler’s leadership, the Fellowship of Medicine responded to demand for postgraduate civilian medical training after the First World War, supported by a general committee of 73 senior medical figures, with representatives from the British Army Medical Service, Medical Services of the Dominions of the United Kingdom, of America and of the British Colleges and major medical Schools. Some fifty general and specialist hospitals were initially affiliated with the Fellowship, which provided sustained support of postgraduate training well into the 1920s, including publication of a weekly bulletin of clinics, ward rounds, special lectures and organized training courses for men and women of all nationalities. In 1925, in response to expanding interest in postgraduate education, the Fellowship developed the bulletin into the Postgraduate Medical Journal, which continues as a monthly international publication. Stimulated by discussions at meetings of the FPM, through its Fellows, the FPM was influential in encouraging London and regional teaching hospitals to develop and maintain postgraduate training courses. The FPM and its Fellows also were important in supporting the creation of a purely postgraduate medical school, which was eventually founded at the Hammersmith Hospital in West London as the British, then Royal Postgraduate Medical School.At the end of the Second World War, there was a major development in provision of postgraduate medical education with the founding in 1945 of the British Postgraduate Medical Federation, which was supported by government, the University Grants Committee and the universities. There was also a marked post-war increase in general provision of postgraduate training at individual hospitals and within the medical Royal Colleges. Postgraduate Centres were established at many hospitals.Nonetheless the FPM continued some involvement in postgraduate courses until 1975. Since then the FPM has maintained a national and international role in postgraduate education through its journals, the Postgraduate Medical Journal and Health Policy and Technology (founded in 2012) and by affiliations with other organisations and institutes.Osler was an avid supporter of engagement between medicine and the humanities, chiding humanists for ignorance of modern science and fellow scientists for neglecting the humanities. The FPM has over much of the past decade supported this theme of Osler by being a major patron of the Hippocrates Prize for Poetry and Medicine, which has achieved significant international interest, with over 10,000 entries from over 70 countries.

Purpose From the Audiology Education Summit held in 2017, several working groups were formed to explore ideas about improving the quality and consistency in graduate education in audiology and externship training. The results are described here from one of the working groups formed to examine postgraduate specialization fellowships. Method Over the course of a year, the committee designed and implemented two surveys: one directed toward faculty and one toward students. The rationale for the survey and the results are presented. Comparisons between faculty and student responses are made for similar questions. Results Overall, the results demonstrate that the majority of both students and faculty believe that postgraduation specialization fellowships are needed for either 1 year or a flexible length. There was a consensus of opinion that the fellowship should be paid, as these would be designed for licensed audiologists. Most believed that the fellowships should be “governed by a professional organization (e.g., American Speech-Language-Hearing Association, American Academy of Audiology, American Doctors of Audiology, etc.),” or less so, a “separate body for this specific purpose.” Potential topics for specialization identified were the following: tinnitus, vestibular, cochlear implants, pediatrics, and intraoperative monitoring. The highest priority attributes for a specialization site were “abundant access to patient populations,” “staff of clinical experts,” and “active research.” The weight put toward these attributes differed between faculty and students with faculty prioritizing “university/academic centers,” and “access to academic coursework in the fellowship area.” The faculty rated “caseload diversity,” “minimum hours,” “research,” and “academic affiliation” as requirements for a fellowship site, with less weight for “coursework” and “other.” Finally, the students valued “improved personal ability to provide exceptional patient care,” “the potential for increased job opportunities,” and the “potential for a higher salary” as benefits most important to them, with lower ratings for “recognition as a subject matter expert” or “potential pathway to Ph.D. program.” Conclusions As a result of the survey, further exploration of a postgraduate specialization fellowship is warranted, especially to determine funding opportunities to offset cost for the sites and to ensure that fellows are paid adequately.

AbstractAs part of the ongoing work by the Committee on the Status of Women in the Profession (CSWP), we offer an empirical analysis of the pipeline problem in academia. The image of a pipeline is a commonly advanced explanation for persistent discrimination that suggests that gender inequality will decline once there are sufficient numbers of qualified women in the hiring pool. The CSWP believes that it is important to ask whether this phenomenon is actually occurring, because the implication is that we can explain inequality as a function of insufficient numbers of trained women in the pool, rather than as a result of ongoing discrimination that requires alternate remedies. Data from the American Association of University Professors suggests that merely increasing the pool of qualified women has not led to a commensurate number of women rising to the top in academia. Women are still ending up in lower paid jobs, and they continue to earn less than men in comparable positions. More aggressive policies to end discrimination are required.

In this interview, Professor Susan Gasser speaks with Storm Johnson, commissioning editor for Epigenomics, on her research on genome stability, epigenetic regulation and chromatin organization, as well as her work supporting women in research. Susan Gasser completed her BA at the University of Chicago, with an honors thesis in biophysics, and her PhD in biochemistry at the University of Basel in 1982, with Gottfried Schatz. She was a postdoc with Ulrich Laemmli at the University of Geneva, which initiated her career-long interest in chromosomes and chromatin structure. She established her own laboratory at the Swiss Institute for Experimental Cancer Research (ISREC) in 1986, focusing on chromatin organization in budding yeast, combining genetics, microscopy and biochemical approaches to understanding silent chromatin and telomeres. In 2001, she was named professor of molecular biology at the University of Geneva and expanded her laboratory's pioneering use of high-resolution time-lapse fluorescence microscopy to study single locus dynamics in the nucleus. From 2004 to 2019, Susan was the Director of the Friedrich Miescher Institute for Biomedical Research in Basel, where she also led a research group until the end of 2020. In Basel, she extended her research interests into heterochromatin in Caenorhabditis elegans. Her laboratory identified the mechanisms that position tissue-specific genes in the nuclei of embryos and of differentiated tissues, combining high throughput molecular analyses with cell biology to determine structure–function relationships in chromatin. Since January 2021, Susan Gasser has been professor invité at the University of Lausanne and Director of the ISREC Foundation, where she is helping shape the new Agora Institute of Translational Cancer Research. She was elected to the Académie de France, Leopoldina, European Molecular Biology Organization (EMBO), American Association for the Advancement of Science and Swiss Academy of Medical Sciences, and she received the French National Institute of Health and Medical Research (INSERM) International Prize in 2011, the Federation of European Biochemical Societies | EMBO Women in Science Award in 2012, the Weizmann Institute Women in Science Award in 2013 and honorary doctorates from the University of Lausanne, the University of Fribourg and Charles University in Prague. In Switzerland, she was the recipient of the Friedrich Miescher Award, the National Latsis Prize and the Otto Naegeli Award for the promotion of medical research. She participates in numerous review boards and advisory committees in Switzerland, across Europe and in Japan; she currently serves on the governing board of the Swiss Federal Institutes of Technology and the Swiss Science Council. From 2000 to 2004, she was vice chairperson, then chairperson of the EMBO Council. Susan led the Gender Committee of the Swiss National Science Foundation from 2014 to 2019 and initiated the Swiss National Science Foundation Prima program for the Promotion of women in academia. She has actively promoted the careers of women scientists in Europe and Japan.

Rokas Bagdonas, Algimantas Tamelis, Rytis Rimdeika, Mindaugas Kiudelis Įvadas / tikslas Didžiausia nudegimų chirurgijos problema yra infekcija, nuo kurios miršta daugiau kaip 50% visų nudegusių pacientų. Nudegimų žaizda greitai infekuojasi, kadangi žaizdos aplinka yra ideali mikroorganizmams atsirasti ir daugintis. Studijoje, patvirtintoje Universiteto etikos komiteto, analizuojami nudegę pacientai ir iš nudegimo žaizdų išskirti patogenai. Pacientai ir metodai Mes analizavome 2246 nudegusius pacientus (amžiaus vidurkis – 27 metai), gydytus KMU Chirurgijos klinikose 1997–2002 metais. Nudegimo sunkumas buvo vertintas pagal Amerikos nudegimų asociacijos (ABA) schemą. 2462 nudegimo žaizdos pasėliai (2246 pacientų) buvo paimti steriliu tamponu ir pasėti 5% kraujo ir MacConkey terpėse. Rezultatai Iš nudegusių pacientų 1447 (74%) buvo vyrai ir 799 (26%) – moterys (p < 0,001). Pacientų amžius – nuo 2 iki 47 metų. 1261 (56%, p < 0,05) pacientai patyrė lengvą, 522 – vidutinį ir 463 – sunkų kūno nudegimą. 2130 pasėliai (86,5%), paimti iš 2462 nudegimo žaizdų, buvo teigiami. Iš 2130 teigiamų pasėlių Staphylococcus aureus išskirtas 1110 (52,1%) pasėliuose, iš jų MRSA – 498 (23,4%). Išvados Jauni vyrai dažniausiai patiria lengvus kūno nudegimus. Nudegimo žaizda dažniausiai infekuojasi S. aureus mikroorganizmais. MRSA yra pagrindinis ligoninės patogenas, infekuojantis nudegimo žaizdą. Prasminiai žodžiai: nudegimo sunkumas, nudegimo žaizdos patogenai, išskirti sukėlėjai Analysis of burn patients and the isolated pathogens Rokas Bagdonas, Algimantas Tamelis, Rytis Rimdeika, Mindaugas KiudelisKaunas Medical University, Clinic of Surgery,Eivenių str. 2, LT-50009, Kaunas, LithuaniaE-mail: rbagdonas@hotmail.com Background / objective The major challenge for a burn team is infection, which is known to cause over 50% of burn deaths. Burns become infected, because the environment at the site of the wound is ideal for the proliferation of infecting organisms. This study, approved by the regional Ethics Committee, analyzes the features of burned patients and the rates of pathogens isolated from burn wounds. Patients and methods We studied 2246 burn patients (mean age 27 years) admitted to the tertiary academic hospital in 1997–2002. The differentiation of the severity of burn injury was based on the scheme of the American Burn Association (ABA). 2462 surface swabs for microbiological analysis were taken from all 2246 patients. The wound area was swabbed with an alginate swab and cultured in 5% blood and MacConkey agar. Results There were 1447 (74%) men and 799 (26%) women (p < 0.001), age range 2–47 years. There were 1261 patients (56%, p < 0.05) with minor, 522 with moderate and 463 with major burn injuries. 2130 swabs (86.5%) out of 2462 burn wound surface swabs were positive. Out of 2130 isolates positive for pathogenic bacterial culture, there were 1110 (52.1%) isolates positive for Staphylococcus aureus infection. The rate of MRSA was 23.4% (498 isolates). Conclusions Young male patients mostly have a minor burn injury. Burn wounds are most commonly infected with S. aureus. MRSA is still the main hospital pathogen in burns. Keywords: severity of the burn injury, burn swabs, isolated pathogens

Abstract Background: Racial and ethnic minorities have well-established disparities in cancer prevention, detection, treatment, and survival. A diverse oncology workforce improves the gap in cancer care for vulnerable populations. However, physicians, researchers, and others who are Underrepresented in Medicine (UIM) face unique challenges in obtaining mentorship and sponsorship, and there is a lack of safe spaces for them to thrive, forcing many to leave medicine entirely. To further efforts in improving the care of vulnerable populations and to create a welcoming environment for UIM medical trainees, the Florez Lab (formerly known as the Duma Lab) was founded by Dr. Narjust Florez in 2019 at the University of Wisconsin. Subsequently, Dr. Florez moved to Dana-Farber Cancer Institute and expanded the lab’s reach. Here, we describe the history and legacy of our innovative group. Methods: The Florez Lab is composed of 39 members, mostly UIM from different backgrounds and locations; members range from college students to faculty. It began as an all-female team but now includes #HeforShe member allies. Several members joined as trainees, but are now junior faculty at NCI designated cancer centers and pay it forward by mentoring the next generation of the Florez Lab. We focus on social justice issues in medicine, including discrimination and gender bias in academic and clinical medicine, global oncology, and cancer health disparities, with a focus on thoracic oncology. Results: To date, the Florez Lab has secured research funding from several institutions and organizations, and has published 15 original articles, 11 editorials, 4 review articles, and 2 book chapters in addition to over 20 poster presentations at national and international conferences. Members have presented research findings at a wide array of national and international conferences, including the American Society of Clinical Oncology (ASCO) Annual Meeting and the World Conference on Lung Cancer, and the American Association for Cancer Research (AACR) Annual Meeting. The lab collaborates with multiple organizations, including the COVID-19 and Cancer Consortium (CCC19), ASCO Health Equity Committee, and the Lancet Commission: Women & Cancer. The lab is far-reaching; the #DumaLab and #FlorezLab hashtag is used on Twitter to amplify published work and advocacy efforts in improving the diversity of the oncology workforce and clinical trial enrollment. In 2021 the Florez Lab began a collaboration with Medscape and is the first lab to have a dedicated column, where we discuss issues related to social justice in medicine and cancer health disparities; the column has reached over 60,000 readers in less than one year. Conclusion: The success of the Florez Lab illustrates the importance of providing opportunities for, supporting, and amplifying the success of UIM trainees. Results indicate that the collaboration of UIM trainees is productive, meaningful, and necessary. Efforts should be made to continue supporting UIM trainees from all backgrounds and levels. Citation Format: Narjust Florez, Inas Abuali, Ana Velazquez, Coral Olazagasti, Idalid Franco, Shruti Patel, Cristiane Bergerot, Paulo Bergerot, Enrique Soto Pérez, Carolina Bernabe-Ramirez, Lauren Kiel. The Florez Lab at Dana-Farber Cancer Institute: Improving the care of vulnerable populations and supporting trainees from underrepresented groups in medicine [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B084.

Background: Missing outcome data in clinical trials are important determinants of internal validity; however, its burden and risk in gestational diabetes mellitus (GDM) mothers supplemented with vitamin D remain poorly studied. Therefore, a systematic review and meta-analysis protocol is proposed here to study it. Methods: The English language publications, irrespective of its publication date, will be searched in electronic databases for randomized controlled trials studying the above outcome. The eligible trials will undergo the risk of bias assessment by the Cochrane tool. Data on its trial design, population characteristics, interventions compared, and the outcome will be abstracted. The prevalence and incidence (in risk ratio) of missing outcome data will be estimated meta-analytically. The statistical heterogeneity assessment will include the use of Chi2 and I2 statistics. For the explanation of any substantial heterogeneity, a meta-regression analysis will ensue. The statistical significance will be determined at P <0.05 and 95% CI. All analyses will be done in Stata statistical software. If the quantitative analysis is not possible, narrative reporting will happen. Results: The reporting of the review will follow the PRISMA guideline. Statistically significant pairwise meta-analysis finding's grading will occur by the GRADE approach. Conclusion: The proposed review will estimate the prevalence of missing outcome data in vitamin D supplemented GDM mothers in clinical trials and compare its risk with the placebo recipients. PROSPERO registration ID: CRD42020180634 References Quintanilla Rodriguez BS, Mahdy H. Gestational Diabetes. [Updated 2019 Dec 23]. StatPearls. Treasure Isl StatPearls Publ. 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545196/ Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstet Gynecol. 2018;131: e49–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29370047 Mack LR, Tomich PG. Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstet Gynecol Clin North Am [Internet]. 2017; 44:207–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28499531 Coustan DR. Gestational Diabetes Mellitus. Clin Chem. 2013; 59:1310–21. Available from: http://www.clinchem.org/cgi/doi/10.1373/clinchem.2013.203331 Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42: S165–72. Available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc19-S014 Saha S. Compliance and barriers to self-monitoring of blood glucose in patients with gestational diabetes mellitus: A systematic review. Int J Health Sci (Qassim).2019;13:44–52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31123440 Akbari M, Mosazadeh M, Lankarani K, Tabrizi R, Samimi M, Karamali M, et al. The effects of vitamin d supplementation on glucose metabolism and lipid profiles in patients with gestational diabetes: a systematic review and meta-analysis of randomized controlled trials. Horm Metab Res.Germany; 2017;49:647–53. Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0043-115225 Saha S, Saha S. A comparison of the risk of cesarean section in gestational diabetes mellitus patients supplemented antenatally with vitamin D containing supplements versus placebo: A systematic review and meta-analysis of double-blinded randomized controlled trials. J Turkish-German Gynecol Assoc. 2020; 21:201–12. https://dx.doi.org/10.4274%2Fjtgga.galenos.2020.2019.0164 Saha SS, Saha SS. The risk of morbidities in newborns of antenatal vitamin D supplemented gestational diabetes mellitus patients. Int J Health Sci (Qassim). Qassim University; 2020; 14:3–17. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475207/ Saha S, Saha S. A Comparison of the Changes in Gestational Weight, Body Mass Index, and Serum Vitamin D Level in Gestational Diabetes Mellitus Patients Complemented with Vitamin D in Contrast to Those Who Did Not Receive the Supplement: A Protocol for Systematic Review a. Int J Diabetes Metab. S. Karger AG; 2019; 25:74–9. https://doi.org/10.1159/000505269 Mavridis D, White IR. Dealing with missing outcome data in meta‐ Res Synth Methods.2020;11:2–13. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/jrsm.1349 Higgins JPT GS (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. Cochrane Collab. 2011 [cited 2020 Aug 27]. Available from: https://training.cochrane.org/handbook/archive/v5.1/ Asemi Z, Hashemi T, Karamali M, Samimi M, Esmaillzadeh A. Effects of vitamin D supplementation on glucose metabolism, lipid concentrations, inflammation, and oxidative stress in gestational diabetes: a double-blind, randomized controlled clinical trial. Am J Clin Nutr.2013;98:1425–32. https://doi.org/10.3945/ajcn.113.072785 Asemi Z, Karamali M, Esmaillzadeh A. Effects of calcium–vitamin D co-supplementation on glycaemic control, inflammation and oxidative stress in gestational diabetes: a randomised placebo-controlled trial. Diabetologia .2014;57:1798–806. https://doi.org/10.1007/s00125-014-3293-x Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary Reference Intakes for Calcium and Vitamin D. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, editors. Washington (DC): National Academies Press (US); 2011. Available from: https://books.google.co.in/books?id=VF2aRQJ6IZ4C Gossman W, Chauhan K, Huecker MR. Vitamin D. StatPearls. 2019. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28722941 Curtis EM, Moon RJ, Harvey NC, Cooper C. Maternal vitamin D supplementation during pregnancy. Br Med Bull. 2018; 126:57–77. https://doi.org/10.1093/bmb/ldy010 Knabl J, Vattai A, Ye Y, Jueckstock J, Hutter S, Kainer F, et al. Role of Placental VDR Expression and Function in Common Late Pregnancy Disorders. I Int J Mol Sci. 2017;18(11):2340. https://doi.org/10.3390/ijms18112340 Yazdchi R, Gargari BP, Asghari-Jafarabadi M, Sahhaf F. Effects of vitamin D supplementation on metabolic indices and hs-CRP levels in gestational diabetes mellitus patients: a randomized, double-blinded, placebo-controlled clinical trial. Nutr Res Pract. 2016; 10:328. Available from: http://synapse.koreamed.org/DOIx.php?id=10.4162/nrp.2016.10.3.328 Jamilian M, Samimi M, Ebrahimi FA, Hashemi T, Taghizadeh M, Razavi M, et al. The effects of vitamin D and omega-3 fatty acid co-supplementation on glycemic control and lipid concentrations in patients with gestational diabetes. J Clin Lipidol. 2017; 11:459–68. https://doi.org/10.1016/j.jacl.2017.01.011 Li Q, Xing B. Vitamin D3-Supplemented Yogurt Drink Improves Insulin Resistance and Lipid Profiles in Women with Gestational Diabetes Mellitus: A Randomized Double Blinded Clinical Trial. Ann Nutr Metab. 2016; 68:285–90. https://doi.org/10.1159/000447433 Karamali M, Bahramimoghadam S, Sharifzadeh F, Asemi Z. Magnesium–zinc–calcium–vitamin D co-supplementation improves glycemic control and markers of cardiometabolic risk in gestational diabetes: a randomized, double-blind, placebo-controlled trial. Appl Physiol Nutr Metab. 2018; 43:565–70. Available from: http://www.nrcresearchpress.com/doi/10.1139/apnm-2017-0521 Hosseinzadeh-Shamsi-Anar M, Mozaffari-Khosravi H, Salami M-A, Hadinedoushan H, Mozayan MR. The efficacy and safety of a high dose of vitamin d in mothers with gestational diabetes mellitus: a randomized controlled clinical trial. Iran J Med Sci. 2012; 37:159–65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23115447 Saha S. Impact of missingness on clinical trials on the effectiveness of antenatal vitamin D supplementation in gestational diabetes mellitus patients. J Ideas Heal. 2020; 3:138–9. https://doi.org/10.47108/jidhealth.Vol3.Iss1.47 Saha S, Saha S. The variation in participant attrition between prenatal vitamin D supplemented and not supplemented gestational diabetes mellitus patients: a systematic review and meta-analysis of randomized controlled trials. PROSPERO. 2020. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020180634 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4:1. https://doi.org/10.1186/2046-4053-4-1 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016; 5:210. https://doi.org/10.1186/s13643-016-0384-4 American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37 Suppl 1: S81-90. https://doi.org/10.2337/dc14-s081 Rossi G, American Diabetes Association. [Diagnosis and classification of diabetes mellitus]. Recenti Prog Med. 2010; 101:274–6. http://www.ncbi.nlm.nih.gov/pubmed/20842952 Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Heal. 2014; 72:39. http://archpublichealth.biomedcentral.com/articles/10.1186/2049-3258-72-39 Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003; 327:557–60. http://www.bmj.com/cgi/doi/10.1136/bmj.327.7414.557 Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004; 328:1490. http://www.bmj.com/lookup/doi/10.1136/bmj.328.7454.1490 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol.2009;62: e1–34. https://doi.org/10.1016/j.jclinepi.2009.06.006

“Research, no matter how ‘good’, is incomplete, until it has been published.”1 In my opinion, otolaryngology residents, fellows and consultants do not lack in research or scholarly capability. However, “the proof of the pudding is (indeed) in the eating,” and scholarly societies are recognized not so much for what goes on within their hallowed halls, but for what are made public outside those walls. Indeed, “publishing” means to make something public.2 And though we may not lack in research, we certainly still lag in publication. I would therefore not be amiss in address the need for PSOHNS fellows, diplomates and trainees to publish, in electronic or hard-copy, in print or other media, including the social media. Because of my background, much of my reflections will deal with writing—but by no means do I mean to limit publication to that of the written word. Why write and publish? “Start Where You Are: Taking Your Place in the History of Scholarship”2 “Similar to others who write (historians and poets), scientists and those involved in research need to write … to leave behind a documented legacy of their accomplishments.”1 Whatever we discover or unearth in the laboratory, clinic or in the field; whether from samples, specimens, subjects, patients or participants; utilizing theoretical or applied instruments, materials and methods; simply “did not happen” unless it is documented and disseminated. In Filipino,“kung hindi nakasulat, hindi nangyari.” How often do we hear comments like “naisip ko na iyan,” or “na-presenta ko na iyan” or even “sinulat ko na iyan” at a scientific meeting where a speaker presents a study. The sad fact of the matter is that many of these colleagues may indeed have had similar thoughts, or delivered previous oral presentations, or even written reports. But because none of these had been properly published, they remain inaccessible to subsequent scholars, and are therefore neither cited nor acknowledged. “While ‘doing’ the research is important, ‘writing’ about why and how it was done, what was found, and what it means is far more important as it serves as a permanent record of scientific work that has been completed and accepted by peers.”1 And writing and publishing are an entirely different ball game from researching alone. Publication, or “making ideas public,” allows “scholars (to) provide each other with the opportunity to build on each other’s contributions, create dialogue (sometimes heated) with one another and join the documented and ongoing history of their field.”2 It is by participating in this “documented and ongoing history” of whatever field we may be in, that we and our specialty society gain international recognition and become internationally competitive. Taking your place in the history of scholarship starts where you are, as an author. Publication involves communication between the author and his or her audience via the written article.3 Unlike public speakers or performing artists, the author’s interaction with the audience is limited by the written and published work. Hence, “a successful researcher is usually a good communicator who has the ability to maximize the transmission of research findings to his or her chosen audience.”1 Setting the Stage: Advantages of Writing and Publication A few may write “for the pleasure derived from the creative activity of writing and intellectual sharing, and the desire to advance knowledge and benefit mankind” and for these individuals, “writing may act as a channel for expressing the joy of scientific discovery, and may even be regarded as a leisurely pursuit.”1 An historical article on Jose Rizal4 that I researched for a year and a half before the occasion of his 150th anniversary and another on the evolution of indirect laryngoscopy5 that I researched for two years are personal examples of these. For most everyone else, there are career, professional, institutional and practical advantages that can be gained from writing and publication.6 As far as career benefits are concerned, “getting published in prestigious, scholarly journals may have the most direct bearing on your appointment, promotion, tenure and advancement within your institution, organization and discipline.”2 The “up or out” situation faced by many young to mid-career academics would have been easily avoided by publishing early. Moreover, publications are the primary basis for promotion and advancement in academe. Professional benefits are just as important. For junior consultants and younger faculty, “having published articles in reputable international journals are a great help when applying for positions in foreign institutions, and when applying for competitive overseas fellowships.”1 As editor of our specialty scholarly journal, I receive numerous urgent requests from postgraduate residents and young diplomates (unaware of the tedious editing and peer review process) to rush-publish research they undertook in training, in fulfillment of publication requirements for overseas positions or fellowships they are applying for. Had they realized this earlier, they would have been much better-prepared. For more established consultants, “gaining recognition as experts in a particular field at regional and international levels leads to invitations to lecture at scientific meetings and refresher courses, and appointments as consultants to external agencies, expert panels and advisory boards, reviewer and editorial boards.”1 Much of my local and international travels are direct offshoots of previous research, lectures and publications. These generate further research and publication opportunities in turn, as track records in research and publication are considered in “applications for, extension of, and further research funding.”1 Closer to home, publication “increases (the) depth of knowledge in a particular subject that complements and hones clinical (practical) skills, and enables better teaching of students, clinical trainees and postgraduates.”1 Indeed, a true professor must have something to profess, and a well-published professor can certainly profess what he or she does more authoritatively. Of course, the practical benefits gained from engaging in the research and publication process cannot be overlooked. The “inherent training gained during the process of manuscript preparation,” the “discipline of performing a thorough literature search, collating and analyzing data and drafting and repeatedly revising the manuscript”1 during the editing and review process, provide undeniable practical benefits to the author. Researchers who have published are much better positioned to evaluate scholarly publications, having themselves experienced the writing, editing and review process. In this era of “information overload” the published researcher can more effectively evaluate and utilize available evidence. Because of institutional benefits, it is in the best interests of our scholarly society to encourage scholarly writing, as “publication in peer-reviewed journals is arguably the most important means to achieve international recognition for an individual, department, hospital, and university.”1 Various international survey and ranking systems place a premium on such publication, explaining why Philippine academic institutions lag behind their counterparts in Asia and the rest of the world. It is also in the best interests of the Philippines that her clinicians, scientists, artists and scholars publish, as “the author’s country, and even the region, may also derive benefit from published work, particularly if it is on a topic of major importance.”1 At least in the medical field, Filipino publications have made their mark, albeit sparsely. The UP College of Medicine and National Health Sciences Journal Acta Medica Philippina is the source of material indelibly inscribed in the world medical map, and we certainly look forward to the Philippine Journal of Otolaryngology Head and Neck Surgery doing the same. The generous research allocation for Fellows and full support for our journal by the PSOHNS Board of Trustees are a step in the right direction, as are the annual awarding of the Outstanding ENT Specialist in Research and Editors’ Pick Outstanding Research Publication. In keeping with international practice, we should accord due public recognition to our excellent Reviewers and Editors at official PSOHNS functions such as Annual Conventions, if but for the recognition they reciprocally bring to the society. The American Academy of Otolaryngology Head and Neck Surgery has journal Editors and Star Reviewers wear special ribbons at their Annual Meeting, and openly campaigns for participants to thank these reviewers for their contribution. On another note, I was elected President 2014-2016 of the Asia Pacific Association of Medical Journal Editors during the recent Joint Meeting of APAME and the Western Pacific Region Index Medicus and Index Medicus of the South East Asia Region of WHO in Ulaanbaatar, Mongolia last August 15 – 17, 2014. This is fortuitous as we prepare to host the APAME Convention 2015 and Joint Meeting with WPRIM and IMSEAR at the WHO Western Pacific Region Office, Sofitel Hotel and Philippine International Convention Center from August 24-26, 2015 in conjunction with FORUM 2015. The other officers are: Executive Vice President Prof. Jeong-Wook Seo (Korea), Vice President for Internal Affairs is Prof. Kiichiro Tsutani (Japan), Vice President for External Affairs Prof. Dai Tao (China), Secretary-General Prof. Wilfred Peh (Singapore). The Philippine Journal of Otolaryngology Head and Neck Surgery is now indexed in the HINARI Access to Research in Health Programme of the World Health Organization www.who.int/hinari making us readily available to a multitude of users from developing countries and increasing our accessibility tremendously. Our society and journal can be accessed via http://extranet.who.int/hinari/en/browse_publisher.php?pub=695 In addition, APAMED Central (on which the Philippine Journal of Otolaryngology Head and Neck Surgery is indexed) has been formally ratified for indexing in the worldwidescience.org database during the World Wide Science Alliance annual meeting in Tokyo last October 2014. Henceforth, all articles from Oct 19 2014, including this issue, will be searchable on this database. Finally, I am especially thankful to our President and my friend, Howard M. Enriquez, MD and the PSOHNS Board of Trustees (especially the Scientific Committee Chair and my friend Elmo R. Lago, Jr., MD) for the support given to me, and our journal on my ninth year as Editor-in-Chief.

Background: The Association of American Medical Colleges and the American Academy of Orthopaedic Surgeons have incorporated diversity and inclusion as one of their primary goals. Orthopaedic surgery remains the least diverse medical specialty when measured for practicing physicians and trainees. The purpose of this study was to determine the number and distinct types of diversity, equity, and inclusion (DEI) positions within orthopaedic surgery residency programs in the United States. Methods: The Fellowship and Residency Electronic Interactive Database was used to obtain a list of all Accreditation Council for Graduate Medical Education–accredited orthopaedic surgery residency programs. The following was collected from 193 residency program websites between June 6, 2022, and June 26, 2022: program location, university or community based, allopathic or osteopathic recognition, number of faculty in the orthopaedic department, number of residents per year, diversity-related statements, and diversity-focused faculty positions. Results: Of the 193 programs evaluated, 74 (38.9%) included DEI statements on their website while only 42 (21.8%) had at least one DEI-specific faculty role (e.g., diversity committee, diversity liaison, vice chair for DEI). For 16 (8.3%) programs, the faculty role was nonspecific to the orthopaedic residency program. Nonspecific roles were primarily created by the affiliated school of medicine, but in 4 (2.1%) outlier cases, faculty members assumed DEI roles through a medical center, a graduate medical education program, or a department of surgery. Conclusions: Less than half of orthopaedic surgery residency programs currently advocate for DEI on their associated websites while fewer than 25% have a DEI faculty position. Previous studies have called for a greater number of DEI positions and committees among orthopaedic residencies because of the lower admittance rate of qualified Under Represented in Medicine (URiM) applicants. A role dedicated to DEI may increase the number of women and URiM applicants pursuing a career in orthopaedic surgery.

Abstract Objective Qualifications needed to achieve national leadership positions in hand surgery are poorly defined. This study compares the academic accomplishments, demographics, and training backgrounds of presidents elected to serve the American Society for Surgery of the Hand (ASSH) and the American Association for Hand Surgery (AAHS). Methods The ASSH and AAHS provided names of elected Presidents (1990–2022, n = 64). Curriculum vitae and academic web sites were used to collect demographic, training, bibliometric, and National Institutes of Health (NIH) funding data of presidents. Results Presidents were predominately male (95%), Caucasian (90%), and orthopaedic surgery residency-trained (66%). Only 9% were racial minorities (8% Asian, 2% Hispanic, and 0% African American). The average age at appointment was 59 ± 7 years old, which was an average of 23 years from completion of hand surgery fellowship. More presidents received plastic surgery residency training in AAHS than ASSH (50 vs. 19%). The most represented hand surgery fellowships were Mayo Clinic (14%), University of Louisville (11%), and Duke University (9%). Twenty-one presidents participated in a travel fellowship (33%). Thirty presidents served as Department Chair or Division Chief at time of election (47%). The average h-index was 34 ± 18 resulting from 164 ± 160 peer-reviewed manuscripts and was similar between the two organizations. Eleven presidents had NIH grant funding (18%) and there were no differences in procurement or funding totals between the two organizations. Conclusion Presidents of American hand surgery societies obtain high levels of scholarly activity regardless of training specialty. Women and racial minorities remain underrepresented at the highest levels of leadership.

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

Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [2] S983A, 2015-2016 Regular Sessions (N.Y. 2015). https://legislation.nysenate.gov/pdf/bills/2015/S983A [3] Chris DiNardo, Pregnancy in Confinement, Anti-Shackling Laws and the “Extraordinary Circumstances” Loophole, 25 Duke Journal of Gender Law & Policy 271-295 (2018) https://scholarship.law.duke.edu/djglp/vol25/iss2/5 [4] Chris DiNardo (2018) [5] U.S. Bureau of Justice Statistics. 1980. " Prisoners in 1980 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/content/pub/pdf/p80.pdf). [6] U.S. Bureau of Justice Statistics. 2022. " Prisoners in 2021 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf). [7] U.S. Bureau of Justice Statistics (1980) [8] Sufrin C, Jones RK, Mosher WD, Beal L. Pregnancy Prevalence and Outcomes in U.S. Jails. Obstet Gynecol. 2020;135(5):1177-1183. doi:10.1097/AOG.0000000000003834 [9] Kramer, C., Thomas, K., Patil, A., Hayes, C. M., & Sufrin, C. B. (2022). Shackling and pregnancy care policies in US prisons and jails. Maternal and Child Health Journal, 27(1), 186–196. https://doi.org/10.1007/s10995-022-03526-y [10] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [11] Goshin, L. S., Sissoko, D. R., Neumann, G., Sufrin, C., & Byrnes, L. (2019). Perinatal nurses’ experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic &amp; Neonatal Nursing, 48(1), 27–36. https://doi.org/10.1016/j.jogn.2018.11.002 [12] Shackling and separation: Motherhood in prison. (2013). AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [13] King, L. (2018). Labor in chains: The shackling of pregnant inmates. Policy Perspectives, 25, 55–68. https://doi.org/10.4079/pp.v25i0.18348 [14] King, L. (2018). [15] AMA Journal of Ethics (2013) [16] Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews, (8). [17] Association of Women’s Health, Obstetric and Neonatal Nurses. (2011). AWHONN position statement: Shackling incarcerated pregnant women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(6), 817–818. doi:10.1111/j.1552-6909.2011.01300.x [18] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [19] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [20] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [21] Griggs, Claire Louise. "Birthing Barbarism: The Unconstitutionality of Shackling Pregnant Prisoners." American University Journal of Gender Social Policy and Law 20, no. 1 (2011): 247-271. [22] American Civil Liberties Union. (2012, October 12). ACLU briefing paper: The shackling of pregnant women & girls in U.S ... American Civil Liberties Union (ACLU). https://www.aclu.org/wp-content/uploads/legal-documents/anti-shackling_briefing_paper_stand_alone.pdf [23] King.L (2018) [24] Griggs, Claire Louise (2011) [25] American Civil Liberties Union. (2012) [26] Clarke, J. G., & Simon, R. E. (2013). Shackling and separation: Motherhood in prison. AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [27] Berg, M. D. (2014, April 18). Pregnant prisoners are losing their shackles - The Boston Globe. BostonGlobe.com. Retrieved March 12, 2023, from https://www.bostonglobe.com/magazine/2014/04/18/taking-shackles-off-pregnant-prisoners/7t7r8yNBcegB8eEy1GqJwN/story.html [28] Levi, R., Kinakemakorn, N., Zohrabi, A., Afanasieff, E., & Edwards-Masuda, N. (2010). Creating the bad mother: How the U.S. approach to pregnancy in prisons violates the right to be a mother. UCLA Women's Law Journal, 18(1). https://doi.org/10.5070/l3181017816 [29] Chris DiNardo (2018) [30] Griggs, Claire Louise (2011). [31] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [32] Nelson v. Correctional, 533 F.3d 958 (8th Cir. 2009) [33] Nelson v. Correctional(2009) [34] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [35] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/ [36] Pendleton, V., Saunders, J. B., & Shlafer, R. (2020). Corrections officers' knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health & justice, 8(1), 1. https://doi.org/10.1186/s40352-019-0102-0 [37] Elizabeth Alexander, Unshackling Shawanna: The Battle Over Chaining Women Prisoners during Labor and Delivery, 32 U. ARK. LITTLE ROCK L. REV. 435 (2010). Available at: https://lawrepository.ualr.edu/lawreview/vol32/iss4/1 [38] Hernandez, J. (2022, April 22). More states are restricting the shackling of pregnant inmates, but it still occurs. NPR. Retrieved March 12, 2023, from https://www.npr.org/2022/04/22/1093836514/shackle-pregnant-inmates-tennessee [39] Sufrin, C. (2012, June 24). End practice of shackling pregnant inmates. SFGATE. Retrieved March 12, 2023, from https://www.sfgate.com/opinion/openforum/article/End-practice-of-shackling-pregnant-inmates-3176987.php [40] Mullings, L. (1997). On our own terms: Race, class, and gender in the lives of African American women. Routledge [41] Ocen, Priscilla A., (2011). [42] Ladd-Taylor, M. (1998). "Bad" mothers: The politics of blame in Twentieth-century America. New York Univ. Press. [43] Hine, D. C. (1998). Hine Sight: Black women and the re-construction of American history. Indiana University Press. [44] Baldwin, L. (2019). Excluded from good motherhood and the impact of prison: Motherhood and Social Exclusion, 129–144. https://doi.org/10.2307/j.ctvk12qxr.13 [45] Ocen, Priscilla A., Punishing Pregnancy: Race, Incarceration, and the Shackling of Pregnant Prisoners (October 3, 2011). California Law Review, Vol. 100, 2012, Available at SSRN: https://ssrn.com/abstract=1937872 [46] Johnson, P. C. (2004). Inner lives: Voices of african american women in prison. New York University Press. [47] Thomas, D. Q. (1996). All too familiar: Sexual abuse of women in U.S. state prisons. Human Rights Watch. [48] Ocen, Priscilla A., (2011). [49] Ashley W. The angry black woman: the impact of pejorative stereotypes on psychotherapy with black women. Soc Work Public Health. 2014;29(1):27-34. doi: 10.1080/19371918.2011.619449. PMID: 24188294. [50] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [51] Guardian News and Media. (2020, January 24). Pregnant and shackled: Why inmates are still giving birth cuffed and bound. The Guardian. Retrieved March 25, 2023, from https://www.theguardian.com/us-news/2020/jan/24/shackled-pregnant-women-prisoners-birth [52] Oparah, J. C. (2015). Birthing justice: Black women, pregnancy, and childbirth. Routledge. [53] Chris DiNardo (2018) [54] Griggs, Claire Louise (2011). [55] Chris DiNardo (2018) [56] Griggs, Claire Louise (2011). [57] Song, Ji Seon, Policing the Emergency Room (June 10, 2021). 134 Harvard Law Review 2646 (2021), Available at SSRN: https://ssrn.com/abstract=3864225 [58] Ocen, Priscilla A., (2011). [59] Staten v. Lackawanna Cnty., No. 4:07-CV-1329, 2008 WL 249988, at *2 (M.D. Pa. Jan. 29, 2008) [60] Lovett, K. (2018, April 9). Pregnant inmates at New York prisons will no longer be shackled under new law. New York Daily News. Retrieved March 12, 2023, from https://www.nydailynews.com/new-york/new-york-pregnant-inmates-no-longer-shackled-article-1.2474021 [61] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [62] Brown v. Plata, 563 U.S. 493 (2011) [63] Nelson v. Correctional Medical Serices, et al., Nelson v. Correctional Med. Servs, 583 F.3d 522 (8th Cir. 2009) [64] Nelson citing Women Prisoners of D.C. Dep't of Corr. v. District of Columbia, 877 F.Supp. 634, 668-69 (D.D.C. 1994), modified in part on other grounds, 899 F.Supp. 659 (D.D.C. 1995). [65] Ark. Dep't of Corr. Admin. Reg. 403 § V (1992) [66] Civil Rights Cases, 109 U.S. 3 (1883) [67] Physician charter. ABIM Foundation. (2022, October 18). Retrieved March 10, 2023, from https://abimfoundation.org/what-we-do/physician-charter#:~:text=Principle%20of%20social%20justice.&text=Physicians%20should%20work%20actively%20to,or%20any%20other%20social%20category. [68] Riddick FA Jr. The code of medical ethics of the american medical association. Ochsner J. 2003 Spring;5(2):6-10. PMID: 22826677; PMCID: PMC3399321. [69] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals: ACOG Committee Opinion, Number 830. Obstetrics and gynecology, 138(1), e24–e34. https://doi.org/10.1097/AOG.0000000000004429 [70] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [71] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [72] Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press. [73] Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 [74] Medical professionalism in the new millennium: A physician charter. (2002). Annals of Internal Medicine, 136(3), 243. https://doi.org/10.7326/0003-4819-136-3-200202050-00012 [75] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [76] Jonsen, A. R. (2010). The Birth of Bioethics. Oxford University Press. [77] Beauchamp, T. L., & Childress, J. F. (2019). [78] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/

Abstract STUDY QUESTION Is exposure to dydrogesterone a risk factor for congenital anomalies when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in assisted reproductive technologies? SUMMARY ANSWER Dydrogesterone, when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in assisted reproductive technologies, is not a relevant additional risk factor for congenital anomalies. WHAT IS KNOWN ALREADY Despite large clinical trials and meta-analyses that show no association between dydrogesterone and congenital anomalies, some recently retracted publications have postulated an association with teratogenicity. Dydrogesterone is also often rated as less safe than bioidentical progestins. STUDY DESIGN, SIZE, DURATION A systematic review was conducted according to a pre-specified protocol with searches on Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and Clinicaltrials.gov. The search was limited to human studies, with no restrictions on language, geographical region, or date. The search algorithm used a PICO (Population, Intervention, Comparison, Outcome)-style approach combining both simple search terms and medical subject heading (MeSH) terms. As congenital anomalies are mostly reported as secondary outcomes, the search term “safety” was added. PARTICIPANTS/MATERIALS, SETTING, METHODS Interventional and observational study designs were eligible for inclusion. Inclusion criteria were: women &gt;17 years treated for threatened miscarriage, recurrent pregnancy loss (RPL) and/or assisted reproductive technologies; the use of dydrogesterone in the first trimester compared with placebo, no treatment or other interventions; and reporting of congenital anomalies in newborns or infants ≤12 months old (primary outcome). Two authors (AK, MN) independently extracted the following data: general study information, study population details, intervention and comparator(s), and frequencies of congenital anomalies (classification, time of determination, and type). Risk of bias focused on the reporting of congenital malformations and was assessed using the Cochrane Risk of Bias Tool Version 2 or the ROBINS-I tool. The GRADEproGDT platform was used to generate the GRADE summary of findings table. MAIN RESULTS AND THE ROLE OF CHANCE Of the 897 records retrieved during the literature search, 47 were assessed for eligibility. Nine studies were included in the final analysis: six randomised controlled trials (RCTs) and three observational studies (OS). Among the RCTs, three had a low risk and three a high risk of bias. Two of the OSs were considered to have a serious risk of bias and one with critical risk of bias and was excluded for the evidence syntheses. The eight remaining studies included a total of 5070 participants and 2680 live-births from 16 countries. In the meta-analysis of RCTs only, the overall relative risk (RR) was 0.92 [95% confidence interval (CI) 0.55; 1.55] with low certainty. When the two OSs were included, the overall RR was 1.11 [95% CI 0.73; 1.68] with low certainty. LIMITATIONS, REASONS FOR CAUTION The studies included in the analysis do not report congenital anomalies as the primary outcome; reporting of congenital anomalies was often not standardized. WIDER IMPLICATIONS OF THE FINDINGS This systematic literature review and meta-analysis provide clear reassurance to both clinicians and patients that dydrogesterone is not associated with congenital anomalies above the rate that might be expected due to environmental and genetic factors. The results of this work represent the highest current level of evidence for the question of congenital anomalies, which removes the existing uncertainty caused by poor quality and retracted studies. STUDY FUNDING/COMPETING INTEREST(S) STUDY FUNDING/COMPETING INTEREST(S): Editorial support was provided by Highfield Communication Consultancy, Oxford, UK, sponsored by Abbott Products Operations AG, Allschwil, Switzerland. AK, JAGV, LS, JvdA, JS received honoraria from Abbott for preparation and participation in an advisory board. JAGV received grants and lecture fees from Merck, Organon, Ferring, Gedeon Richter, and Theramex. MN has no conflicts of interest. JvdA, JAGV have no other conflicts of interest. AK received payment from Abbott for a talk at the IVF Worldwide congress on 22 September, 2023. JS has received grants from the National Institutes of Health, royalties/licences from Elsevier and Prescient Medicine (SOLVD Health), consulting fees from Burroughs Wellcome Fund (BWF) and Bayer, honoraria from Magee Women's Research Institute, Wisconsin National Primate Research Centre, University of Kansas and Oakridge National Research Laboratory, Agile, Daiichi Sankyo/American Regent and Bayer, and travel support to attend meetings for the International Academy of Human Reproduction (IAHR). JS has patents related to diagnosis and treatment of PCOS and prediction of preterm birth. JS participates on advisory boards for SOLVD Health, Wisconsin National Primate Research Centre, and FHI360, was the past President board member of the Society for Reproductive Investigation, and has a leadership role for the following organizations: Scientific Advisory Board, SOLVD Health, EAB Chair for contraceptive technology initiative, FHI360, EAB member, Wisconsin National Primate Research Centre, Advisory Board for MWRI Summit, Chair of BWF NextGen Pregnancy Research Panel, Medical Executive Committee at the Howard and Georgeanna Jones Foundation, and is Vice President, IAHR. LS has received consulting fees from Shield Pharmaceuticals, Scynexis, Organon, Natera, Celula China, AiVF, Agile, Daiichi Sankyo, American Regent and Medicem, honoraria from Agile, Daiichi Sankyo/American Regent and Bayer, and travel support from BD Diagnostics. LS participates on the data safety monitoring board for Astellas, and is Chair of DSMB for fezolinetant. Abbott played no role in the funding of the study or in study design, data collection, data analysis, data interpretation or writing of the report. TRIAL REGISTRATION NUMBER PROSPERO 2022 CRD42022356977

The story of Barbie is a tapestry woven with threads of cultural significance, societal shifts, and corporate narratives. It’s a tale that encapsulates the evolution of American post-war capitalism, mirroring the changing tides of social norms, aspirations, and identities. Barbie’s journey from Germany to Los Angeles, along the way becoming a global icon, is a testament to the power of Ruth Handler’s vision and Barbie’s marketing. Barbie embodies and reflects the rise of mass consumption and the early days of television advertising, where one doll could become a household name and shape the dreams of children worldwide. The controversies and criticisms surrounding Barbie – from promoting a ‘thin ideal’ to perpetuating gender and racial stereotypes – highlight the complexities of representation in popular culture. Yet, Barbie’s enduring message, “You can be anything”, continues to inspire and empower, even as it evolves to embrace a more inclusive and diverse portrayals of power, beauty, and potential. Barbie’s story is not just about a doll; it’s about the aspirations she represents, the societal changes she’s witnessed, and the ongoing conversation about her impact on gender roles, body image, and consumer culture. It’s a narrative that continues to unfold, as Barbie adapts to the times and remains a symbol of possibility. Barbie: A Popular Culture Icon “It is impossible to conceive of the toy industry as being anything other than dependent on a popular culture which shapes and structures the meanings carried by toys” (Fleming 40). The relationship between toys and popular culture is symbiotic. While popular culture influences the creation of toys, toys also contribute to the spread and longevity of cultural icons and narratives. Today, one of the most influential, popular, and contested toys of the twentieth century is Mattel’s Barbie doll. Her launch at the New York Toy Fair on 9 March 1959 by Mattel co-founder Ruth Handler was a game-changer in the toy industry. Her adult appearance, symbolised by her fashionable swimsuit and ponytail, was a bold move by Mattel. Despite the doubts from the toy industry which thought nobody would want to play with a doll that had breasts (Tamkin) and Mattel’s skepticism of its commercial success (Westenhouser 14), Barbie was a success, selling over 350,000 units in her first year, and she quickly became an iconic figure, paving the way for other male and female adult dolls. For the first time in mid-century America, Barbie meant children could play with a doll that looked like a woman, not a little girl or a baby. In a 1965 interview, Ruth Handler argued that American girls needed a doll with a “teen-age figure and a lot of glorious, imaginative, high-fashion clothes” (cited in Giacomin and Lubinski 3). In a 1993 interview, Handler said it was “important that Barbie allowed play situations that little girls could project themselves into … to imagine, pretend and to fantasize”. Hence Ruth Handler’s Barbie could be an “avatar for girls to project their dreams onto” (Southwell). Barbie hit the market with a “sassy ponytail, heavy eyeliner, a healthy dose of side-eye and a distinctly adult body” (Blackmore). Her arched eyebrows were matched with a coy sideways glance reflecting her sexual origins (Thong). Mattel did not reveal that Ruth Handler’s Barbie was inspired by a German novelty men’s toy, Bild Lilli, which Handler had purchased on a European holiday in 1955. Mattel fought several lawsuits and eventually secured the rights to Bild Lilli in 1964, which required the German maker of the Bild Lilli doll to not make her again. Barbie dolls, both blonde and brunette, changed little until 1967, when Mattel launch the ‘new’ Barbie doll which is the foundation for today’s Stereotypical Barbie. The same size as the original, thanks to Mattel engineer Jack Ryan she could twist and turn at the waist. Her facial features were softened, she had ‘real’ eyelashes’ and took on an ‘outdoor look’. The new 1967 version of Barbie originally retailed for US$3.00. Mattel, assuming consumers may not want to buy a new Barbie when they already had one, offered buyers the new Barbie at US$1.50 if they traded in their old 1950s Barbie. The television advertising campaign for the new Barbie featured Maureen McMormick (who would go on to play Marcia Brady in the TV series The Brady Bunch from 1969 to 1974). The original #1 Barbie today sells for over US$25,000 (Reinhard). The most expensive Barbie sold to date was a Stefano Canturi-designed Barbie that sold in 2010 for US$302,500 at Christies in New York (Clarendon). Barbie has been described as “the most successful doll in history”, “the most popular toy in history”, the “empress of fashion dolls” (Rogers 86), the “most famous doll in the world” (Ferorelli), the biggest-selling fashion doll in history (Green and Gellene), and is one if the world’s “most commercially successful toys” (Fleming 41). Barbie is both “idealistic and materialistic” and characterises an “American fantasy” (Tamkin). More so, she is a popular culture icon and “a unique indicator of women’s history” (Vander Bent). The inclusion of Barbie in America’s twentieth-century Time Capsule “cemented her status as a true American icon” (Ford), as did Andy Warhol when he iconised Barbie in his 1968 painting of her (Moore). During the 1950s and 1960s, Barbie’s name was licenced to over 100 companies; while a strategic move that expanded Barbie’s brand presence, it also provided Mattel with substantial royalty payments for decades. This approach helped solidify Barbie’s status as a cultural icon and enabled her to become a lucrative asset for Mattel (Rogers). Sixty-five years later, Barbie has 99% global brand awareness. In 2021, Mattel shipped more than 86 million Barbies globally, manufacturing 164 Barbies a minute (Tomkins). In 2022, Barbie generated gross sales of US$1.49 billion (Statista 2023). With this fiscal longevity and brand recognition, the success of the Barbie film is not surprising. The 2023 film, directed by Greta Gerwig and starring Australian Margot Robbie as Barbie and Canadian Ryan Gosling as Ken, as of March 2024 has a global box office revenue of US$1.45 billion, making it the 14th most successful movie of all time and the most successful movie directed by a woman (Statista 2024). Contested Barbie Despite her popularity, Barbie has been the subject of controversy. Original Barbie’s proportions have been criticised for promoting an unrealistic body image (Thong). Barbie’s appearance has received numerous critiques for “representing an unrealistic beauty standard through its former limited skin tone and hair combination” (Lopez). The original Barbie’s measurements, if scaled to life-size, would mean Barbie is unusually tall and has a slim figure, with a height of 5 feet 9 inches, a waist of just 18 inches, and hips of approximately 33 inches. Her bust would measure around 32 inches with an under-bust of 22 inches, and her shoulder width would be approximately 28 inches. Original Barbie’s legs, which are proportionally longer than an average human’s, would make up more than half her height (Thong). A 1996 Australian study scaled Barbie and Ken to adult sizes and compared this with the physical proportions of a range of women and men. They found that the likelihood of finding a man of comparable shape to Ken was 1 in 50. Barbie was more problematic. The chance of a woman being the same proportion as Barbie was 1 in 100,000 (Norton et al. 287). In 2011, The Huffington Post’s Galia Slayen built a life-sized Barbie based on Barbie’s body measurements for National Eating Disorder Awareness Week. Slayen concluded that “if Barbie was a real woman, she’d have to walk on all fours due to her proportions”. One report found that if Barbie’s measurements were those of a real woman her “bones would be so frail, it would be impossible for her to walk, and she would only have half a liver” (Golgowski). A 2006 study found that Barbie is a “possible cause” for young girls’ “body dissatisfaction”. In this study, 162 girls from age 5 to 8 were exposed to images of a thin doll (Barbie), a plus-size doll (US doll Emme, size 16), or no doll, and then completed assessments of body image. Girls exposed to Barbie reported “lower body esteem and greater desire for a thinner body shape than girls in the other exposure conditions”. The study concluded that “early exposure to dolls epitomizing an unrealistically thin body ideal may damage girls' body image, which would contribute to an increased risk of disordered eating and weight cycling” (Dittman and Halliwell 283). Another study in 2016 found that “exposure to Barbie” led to “higher thin-ideal internalization”, but found that Barbie had no “impact on body esteem or body dissatisfaction” (Rice et al. 142). In response to such criticism, Mattel slowly introduced a variety of Barbie dolls with more diverse body types, including tall, petite, and curvy models (Tamkin). These changes aim to reflect a broader range of beauty standards and promote a more positive body image. Barbie has always had to accommodate social norms. For this reason, Barbie always must have underpants, and has no nipples. One of the reasons why Ruth Handler’s husband Elliott (also a co-founder of Mattel) was initially against producing the Barbie doll was that she had breasts, reportedly saying mothers would not buy their daughters a doll with breasts (Gerber). Margot Robbie, on playing Barbie, told one news outlet that while Barbie is “sexualized”, she “should never be sexy” (Aguirre). Early prototypes of Barbie made in Japan in the 1950s sexualised her body, leaving her to look like a prostitute. In response, Mattel hired film make-up artist Bud Westmore to redo Barbie’s face and hair with a softer look. Mattel also removed the nipples from the prototypes (Gerber). Barbie’s body and fashion have always seemed to “replicate history and show what was what was happening at the time” (Mowbray), and they also reflect how the female body is continually surveilled. Feminists have had a long history of criticism of Barbie, particularly her projection of the thin ideal. At the 1970 New York Women’s Strike for Equality, feminists shouted “I am not a Barbie doll!” Such debates exemplify the role and impact of toys in shaping and reforming societal norms and expectations. Even the more recent debates regarding the 2023 Barbie film show that Barbie is still a “lightning rod for the messy, knotty contradictions of feminism, sexism, misogyny and body image” (Chappet). Decades of criticism about Barbie, her meaning and influence, have left some to ask “Is Barbie a feminist icon, or a doll which props up the patriarchy?” Of course, she’s both, because “like all real women, Barbie has always been expected to conform to impossible standards” (Chappet). Diversifying Barbie Over the decades Mattel has slowly changed Barbie’s body, including early versions of a black Barbie-like dolls in the 1960s and 1970s such as Francie, Christie, Julia, and Cara. However, it was not until 1980 that Mattel introduced the first black Barbie. African American fashion designer Kitty Black-Perkins, who worked for Mattel from 1971, was the principal designer for black Barbie, saying that “there was a need for the little Black girl to really have something she could play with that looked like her” (cited in Lafond). Black Barbie was marketed as She’s black! She’s beautiful! She’s dynamite! The following year, Asian Barbie was introduced. She was criticised for her nondescript country of origin and dressed in an “outfit that was a mishmash of Chinese, Korean and Japanese ethnic costumes” (Wong). More recently, the Asian Barbies were again criticised for portraying stereotypes, with a recent Asian Barbie dressed as a veterinarian caring for pandas, and Asian violinist Barbie with accompanying violin props, reflecting typical stereotypes of Asians in the US (Wong). In 2016, Mattel introduced a range of Barbie and Ken dolls with seven body types, including more curvy body shapes, 11 skin tones and 28 hairstyles (Siazon). In 2019, other Barbie body types appeared, with smaller busts, less defined waist, and more defined arms. The 2019 range also included Barbies with permanent physical disabilities, one using a wheelchair and one with a prosthetic leg (Siazon). Wheelchair Barbie comes with a wheelchair, and her body has 22 joints for body movement while sitting in the wheelchair. The Prosthetic Barbie comes with a prosthetic leg which can be removed, and was made in collaboration with Jordan Reeve, a 13-year-old disability activist born without a left forearm. In 2020, a No Hair Barbie and a Barbie with the skin condition vitiligo were introduced, and in 2022, Hearing Aid Barbie was also launched. In 2022 other changes were made to Barbie’s and Ken’s bodies, with bodies that became fuller figured and Kens with smaller chests and less masculine body shapes (Dolan). Down Syndrome Barbie was released in 2023, designed in collaboration with the US National Down Syndrome Society to ensure accurate representation. By 2024, Barbie dolls come in 35 skin tones, 97 hairstyles, and nine body types (Mattel 2024). Spanning hundreds of iterations, today the Barbie doll is no longer a homogenous, blond-haired, blue-eyed toy, but rather an evolving social phenomenon, adapting with the times and the markets Mattel expands into. With dolls of numerous ethnicities and body types, Barbie has also embraced inclusivity, catering to the plethora of different consumers across the world (Green and Gellene 1989). Career Barbie While not dismissing Barbie’s problematic place in feminist, gender and racial critiques, Barbie has always been a social influencer. Her early years were marked by a variety of makeovers and modernisations, as have recent changes to Barbie’s body, reflecting the changing social norms of the times. Stereotypical Barbie had her first major makeover in 1961, with her ponytail swapped for a short ‘Bubble Bob’ hairstyle inspired by Jackie Kennedy and Marilyn Monroe, reflecting women’s emerging social independence (Foreman). In the early 1970s, Barbie’s original demure face with averted eyes was replaced by a new one that “depicted confidence and a forward-facing gaze” (Vander Bent). Her “soft look” was a departure from the mature image of the original 1959 Barbie (Lafond). The ‘soft look’ on Malibu Barbie with her newly sculpted face featured an open smile for the first time, as well as sun-tanned, make-up free skin and sun-kissed blonde hair. The disappearance of Barbie’s coy, sideways glance and the introduction of forward-looking eyes was a development “welcomed by feminists” (Ford). Barbie’s early makeovers, along with her fashion and accessories, including her homes, cars, and pets, contributed to shaping her image as a fashionable and independent woman. Barbie’s various careers and roles have been used to promote ideas of female empowerment. From astronaut to presidential candidate, Barbie has broken barriers in traditionally male-dominated fields. However, the effectiveness of these efforts in promoting female empowerment is a topic of debate. The post-war period in America saw a significant shift in the pattern of living, with a move from urban areas to the suburbs. This was facilitated by a robust post-war economy, favourable government policies like the GI Bill, and increasing urbanisation. The GI Bill played a crucial role by providing low-interest home loans to veterans, making home ownership accessible to a large segment of the population. It was a significant transformation of the American lifestyle and shaped the country’s socio-economic landscape. It is in this context that Barbie’s first Dreamhouse was introduced in the early 1960s, with its mid-century modern décor, hi-fi stereo, and slim-line furniture. This was at a time when most American women could not get a mortgage. Barbie got her first car in 1962, a peach-colored Austin-Healey 3000 MKII convertible, followed short afterwards by a Porsche 911. She has also owned a pink Jaguar XJS, a pink Mustang, a red Ferrari, and a Corvette. Barbie’s car choices of luxurious convertibles spoke to Barbie’s social and economic success. In 1998, Barbie became a NASCAR driver and also signed up to race in a Ferrari in the Formula 1. Barbie’s ‘I Can Be Anything’ range from 2008 was designed to draw kids playing with the dolls toward ambitious careers; one of those careers was as a race car driver (Southwell). While Barbie’s first job as a baby-sitter was not as glamourous or well-paying as her most of her other over 250 careers, it does reflect the cultural landscape Barbie was living in in the 1960s. Babysitter Barbie (1963) featured Barbie wearing a long, pink-striped skirt with ‘babysitter’ emblasoned along the hem and thick-framed glasses. She came with a baby in a crib, a telephone, bottles of soda, and a book. The book was called How to Lose Weight and had only two words of advice, ‘Don’t Eat’. Even though there was a backlash to the extreme dieting advice, Mattel included the book in the 1965 Slumber Party Barbie. Barbie wore pink silk pajamas with a matching robe and came prepared for her sleepover with toiletries, a mirror, the controversial diet book, and a set of scales permanently set at 110 pounds (approx. 50kg), which caused further backlash (Ford). Barbie’s early careers were those either acceptable or accessible to women of the era, such as the Fashion Designer Barbie (1960), Flight Attendant Barbie (1961), and Nurse Barbie (1962). However, in 1965 Barbie went into space, two years after cosmonaut Valentina Tereshkova became the first woman in space, and four years before the American moon landing. Barbie’s career stagnated in the 1970s, and she spends the decade being sports Barbie, perhaps as a response to her unpopularity among vocal second wave feminists and reflecting the economic downturn of the era. America’s shift to the right in the 1980s saw in the introduction of the Yuppie, the young urban professional who lived in the city, had a high-powered career, and was consumption-driven. More women were entering the workforce than ever before. Barbie also entered the workforce, spending less time doing the passive leisure of her earlier self (Ford). It also signals the beginning of neoliberalism in America, and a shift to individualism and the rise of the free market ethos. In 1985, Day-to-Night Barbie was sold as the first CEO Barbie who “could go from running the boardroom in her pink power suit to a fun night out on the town”. For Mattel she “celebrated the workplace evolution of the era and showed girls they could have it all”. But despite Barbie’s early careers, the focus was on her "emphasized femininity”, meaning that while she was now a career woman, her appearance and demeanor did not reflect her job. Astronaut Barbie (1985) is a good example of Barbie’s ‘emphasised femininity’ in how career Barbies were designed and dressed. Astronaut Barbie is clearly reflecting the fashion and culture trends of the 1980s by going into space in a “shiny, hot pink spacesuit”, comes with a second space outfit, a shiny “peplum miniskirt worn over silver leggings and knee-high pink boots” (Bertschi), and her hair is too big to fit into the helmet. A dark-skinned US Astronaut Barbie was released in 1994, which coincided with the start of the Shuttle-Mir Program, a collaboration between the US and Russia which between 1994 and 1998 would see seven American astronauts spend almost 1,000 days living in orbit with Russian cosmonauts on the Mir space station. Throughout the 1990s, Barbie increasingly takes on careers more typically considered to be male careers. But again, her femininity in design, dressing and packaging takes precedence over her career. Police Officer Barbie (1993), for example, has no gun or handcuffs. Instead, she comes with a "glittery evening dress" to wear to the awards dance where she will get the "Best Police Officer Award for her courageous acts in the community”. Police Office Barbie is pictured on the box "lov[ing] to teach safety tips to children". Barbie thus “feminizes, even maternalises, law enforcement” (Rogers 14). In 1992, Teen Talk Barbie was released. She had a voice box programmed to speak four distinct phrases out of a possible 270. She sold for US$25, and Mattel produced 350,000, expecting its popularity. The phrases included ‘I Love Shopping’ and ‘Math class is tough’. The phrase ‘Math class is tough’ was seen by many as reinforcing harmful stereotypes about girls and math. The National Council of American Teachers of Maths objected, as did the American Association of University Women (NYT 1992). In response to criticisms of the gendered representations of Barbie’s careers, Mattel have more recently featured Barbie in science and technology fields including Paleontologist Barbie (1996 and 2012), Computer Engineer Barbie (2010), Robotics Engineer Barbie (2018), Astrophysicist Barbie (2019), Wildlife Conservationist Barbie, Entomologist Barbie (2019), and Polar Marine Biologist Barbie (all in collaboration with National Geographic), Robotics Engineer Barbie (2018), Zoologist Barbie (2021), and Renewable Energy Barbie (2022), which go some way to providing representations that at least encompass the ideal that ‘Girls Can Do Anything’. Barbie over her lifetime has also taken on swimming, track and field, and has been a gymnast. Barbie was an Olympic gold medallist in the 1970s, with Mattel releasing four Barbie Olympians between 1975 and 1976, arguably cashing in on the 1976 Montreal Olympics. Gold Medal Barbie Doll Skier was dressed in a red, white, and blue ski suit completed with her gold medal. Gold Medal Barbie Doll is an Olympic swimmer wearing a red, white, and blue tricot swimsuit, and again wears an Olympic gold medal around her neck. The doll was also produced as a Canadian Olympian wearing a red and white swimsuit. Gold Medal Barbie Skater looks like Barbie Malibu and is dressed in a long-sleeved, pleated dress in red, white, and blue. The outfit included white ice skates and her gold medal. Mattel also made a Gold Medal P.J. Gymnast Doll who vaulted and somersaulted in a leotard of red, white, and blue tricot. She had a warm-up jacket with white sleeves, red cuffs, white slippers, and a gold medal. Mattel, as part of a licencing agreement with the International Olympic Committee, produced a range of toys for the 2020 Tokyo Olympics. The collection of five Barbies represented the new sports added to the 2020 Olympics: baseball and softball, sport climbing, karate, skateboarding, and surfing. Each Barbie was dressed in a sport-specific uniform and had a gold medal. Barbie Olympic Games Tokyo 2020 Surfer, for example, was dressed in a pink wetsuit top, with an orange surfboard and a Tokyo 2020 jacket. For the 2022 Winter Olympics and Paralympics, Mattel released a new collection of Barbie dolls featuring among others a para-skiing Barbie who sits on adaptive skis and comes with a championship medal (Douglas). As part of Mattel’s 2023 Barbie Career of the Year doll, the Women in Sports Barbie range shows Barbie in leadership roles in the sports industry, as manager, coach, referee, and sport reporter. General Manager Barbie wears a blue-and-white pinstripe suit accessorised with her staff pass and a smartphone. Coach Barbie has a pink megaphone, playbook, and wears a two-piece pink jacket and athletic shorts. Referee Barbie wears a headset and has a whistle. Sports Reporter Barbie wears a purple, geometric-patterned dress and carries a pink tablet and microphone (Jones). Political Barbie Barbie has run for president in every election year since 1992. The first President Barbie came with an American-themed dress for an inaugural ball and a red suit for her duties in the Oval Office. In 2016, Barbie released an all-female presidential ticket campaign set with a president and vice-president doll. The 2000 President Barbie doll wore a blue pantsuit and featured a short bob cut, red lipstick pearl necklace, and a red gown to change into, “presumably for President Barbie’s inaugural ball” (Lafond). This followed the introduction of UNICEF Ambassador Barbie in 1989. She is packaged as a member of the United States Committee for UNICEF (United Nations International Children’s Emergency Fund), which is mandated to provide humanitarian and development aid to children worldwide. Rather problematically, and again with a focus on her femininity rather than the importance of the organisation she represents, she wears a glittery white and blue full length ball gown with star patterning and a red sash. While some proceeds did go to the US Committee for UNICEF, the dressing and packaging featuring an American flag overshadows the career and its philanthropic message. The period signalled the end of the Cold War and was also the year the United States invaded Panama, resulting in a humanitarian disaster when US military forces attacked urban areas in order to overthrow the Noriega administration. Military Barbie Barbie has served in every US military branch (Sicard). Barbie joined the US army in 1989, wearing a female officer’s evening uniform, though with no sense of what she did. While it may be thought Barbie would increase female in interest in a military career, at the time more women were already enlisting that in any other period from the early 1970s to 2012 (Stillwell). Barbie rejoined the army for the 1990-1991 Gulf War, wearing a Desert Combat Uniform and the 101st Airborne "Screaming Eagle" patch, and serving as a medic. Barbie also joined the Air Force in 1990, three years before Jeannie Leavitt became the first female Air Force fighter pilot. Barbie wore a green flight suit and leather jacket, and gold-trimmed flight cap. She was a fighter pilot and in 1994, she joined the USAF aerial demonstration team, The Thunderbirds. Busy in the 1990s, she also enlisted in the US Navy wearing women's Navy whites. Marine Corps Barbie appeared in 1992, wearing service and conduct medals (Stillwell). All of Barbie’s uniforms were approved by the Pentagon (Military Women’s Memorial). The 2000 Paratrooper Barbie Special Edition was released with the packaging declaring “let’s make a support drop with first aid and food boxes”. She was dressed in undefined military attire which includes a helmet, dog tags, parachute, boots, and hairbrush. Barbie’s Influence In 2014, Barbie became a social media influencer with the launch of the @barbiestyle Instagram account, and in 2015, Barbie launched a vlog on YouTube to talk directly to girls about issues they face. The animated series features Barbie discussing a range of topics including depression, bullying, the health benefits of meditation, and how girls have a habit of apologising when they don’t have anything to be sorry about. The Official @Barbie YouTube channel has over eleven million global subscribers and 23 billion minutes of content watched, making Barbie the #1 girls’ brand on YouTube. Barbie apps average more than 7 million monthly active users and the Instagram count boasts over 2 million followers. The 2023 Barbie film really does attest to Barbie’s influence 70 years after her debut. Barbie, as this article has shown, is more than an influencer and more than a doll, if she ever really was only a doll. She is a popular culture icon, regardless of whether we love her or not. Barbie has sometimes been ahead of the game, and sometimes has been problematically represented, but she has always been influential. Her body, race, ability, careers, independence, and political aspirations have spoken different things to those who play with her. She is fiercely defended, strongly criticised, and shirks from neither. She is also liberating, empowering, straight, and queer. As the articles in this issue reflect, Barbie, it seems, really can be anything. Imagining and Interrogating Barbie in Popular Culture The feature article in this issue outlines how Australian Barbie fans in the 1960s expressed their creativity through the designing and making of their own wardrobes for the doll. Through examining articles from the Australian Women’s Weekly, Donna Lee Brien reveals this rich cultural engagement that was partly driven by thrift, and mostly by enjoyment. Eva Boesenberg examines the social and environmental effects of a plastic doll that is positioned as an ecological ambassador. While there is no doubt that climate change is one of our most pressing social issues, Boesenberg questions the motivations behind Barbie’s eco-crusade: is she an apt role-model to teach children the importance of environmental issues, or is this just a case of corporate greenwashing? Emma Caroll Hudson shifts the focus to entertainment, with an exploration of the marketing of the 2023 blockbuster film Barbie. Here she argues that the marketing campaign was highly successful, utilising a multi-faceted approach centred on fan participation. She highlights key components of the campaign to reveal valuable insights into how marketing can foster a cultural phenomenon. Revna Altiok’s article zooms in on the depiction of Ken in the 2023 film, revealing his characterisation to be that of a ‘manic pixie dream boy’ whose lack of identity propels him on a journey to self-discovery. This positioning, argues Altiok, pulls into focus social questions around gender dynamics and how progress can be truly achieved. Rachel Wang turns the spotlight to Asian identity within the Barbie world, revealing how from early iterations a vague ‘Oriental’ Barbie was accompanied by cultural stereotyping. Despite later, more nuanced interpretations of country-specific Asian dolls, problematic features remained embedded. This, Wang argues, positions Asian Barbies as the racial ‘other’. Kaela Joseph, Tanya Cook, and Alena Karkanias’s article examines how the 2023 Barbie film reflects different forms of fandom. Firstly, Joseph interrogates how the Kens’ patriarchal identity is expressed through acts of collective affirmational fandom. Here, individual fans legitimise their positions within the group by mastering and demonstrating their knowledge of popular culture phenomena. Joseph contrasts this with transformational fandom, which is based upon reimagining the source material to create new forms. The transformation of the titular character of the Barbie movie forms the basis of Eli S’s analysis. S examines how the metaphor of ‘unboxing’ the doll provides an avenue through which to understand Barbie’s metamorphosis from constrained doll to aware human as she journeys from the pink plastic Barbie Land to the Real World. Anna Temel turns her critical gaze to how the 2023 film attempts to reposition Barbie’s image away from gender stereotypes to a symbol of feminist empowerment. Director Greta Gerwig, Temel argues, critiques the ‘ideal woman’ and positions Barbie as a vehicle through which contemporary feminism and womanhood can be interrogated. Temel finds that this is not always successfully articulated in the depiction of Barbie in the film. The reading of the Barbie movie’s Barbie Land as an Asexual Utopia is the focus of Anna Maria Broussard’s article. Here Broussard draws the focus to the harmonious community of dolls who live without social expectations of sexuality. Barbie provides a popular culture reflection of the Asexual experience, expressed through Barbie’s rejection of a heteronormative relationship both in Barbie Land and the Real World. Completing this collection is Daisy McManaman’s article interrogating the multiple iterations of the doll’s embodied femininity. Incorporating an ethnographic study of the author’s relationship with the doll, McManaman uncovers that Barbie serves as a site of queer joy and a role model through which to enjoy and explore femininity and gender. These articles have been both intellectually stimulating to edit, and a joy. We hope you enjoy this collection that brings a new academic lens to the popular cultural phenomenon that is Barbie. References Aguirre, Abby. “Barbiemania! Margot Robbie Opens Up about the Movie Everyone’s Waiting For.” Vogue, 24 May 2023. 16 Mar. 2024 <https://www.vogue.com/article/margot-robbie-barbie-summer-cover-2023-interview>. Bertschi, Jenna. “Barbie: An Astronaut for the Ages.” Smithsonian National Air and Space Museum, 18 Jul. 2023. 11 Mar. 2024 <https://airandspace.si.edu/stories/editorial/barbie-astronaut-ages>. Blackmore, Erin. “Barbie’s Secret Sister Was a German Novelty Doll.” History.com, 14 Jul. 2023. 11 mar. 2024 <https://www.history.com/news/barbie-inspiration-bild-lilli>. Chappet, Marie-Claire. “Why Is Barbie So Controversial? How Ever-Changing Standards for Women Have Affected the Famous Doll.” Harpers Bazaar, 18 Jul. 2023. 11 Mar. 2024 <https://www.harpersbazaar.com/uk/culture/culture-news/a44516323/barbie-controversial-figure/>. Clarendon, Dan. “The Most Valuable Barbie Doll Auctioned for $302,500 — Which Others Carry Value?” Market Realist, 14 Apr. 2023. 15 Mar. 2o24 <https://marketrealist.com/fast-money/most-valuable-barbies/>. Dittman, Helga, and Emma Halliwell. “Does Barbie Make Girls Want to Be Thin? The Effect of Experimental Exposure to Images of Dolls on the Body Image of 5- to 8-Year Old Girls.” Developmental Psychology 42.2 (2006): 283-292. DOI: 10.1037/0012-1649.42.2.283. Dolan, Leah. “Barbie Unveils Its First-Ever Doll with Hearing Aids.” CNN, 11 May 2022. 16 Mar. 2024 <https://edition.cnn.com/style/article/barbie-hearing-aid-ken-vitiligo/index.html>. Douglas, Kelly. “Why the New Para Skiing Barbie Is Groundbreaking for Disability Representation.” The Mighty, 21 Oct. 2023. 25 Mar. 2024 <https://themighty.com/topic/disability/para-skiing-barbie-disability-representation/>. Ferorelli, Enrico. “Barbie Turns 21.” Life, Nov. 1979. 15 Mar. 2024 <https://chnm.gmu.edu/cyh/primary-sources/310.html>. Fleming, Dan. Powerplay: Toys as Popular Culture. Manchester: Manchester UP, 1996. Ford, Toni Marie. “The History of the Barbie Doll.” Culture Trip, 6 Oct. 2016. 16 Mar. 2024 <https://theculturetrip.com/north-america/usa/articles/the-history-of-the-barbie-doll>. Foreman, Katya. “The Changing Faces of Barbie.” BBC, 11 May 2016. 16 Mar. 2024 <https://www.bbc.com/culture/article/20160511-the-changing-faces-of-barbie>. Gerber, Ruth. Barbie and Ruth: The Story of the World's Most Famous Doll and the Woman Who Created Her. HarperCollins, 2009. Giacomin, Valeria, and Christina Lubinski. 2023. “Entrepreneurship as Emancipation: Ruth Handler and the Entrepreneurial Process ‘in Time’ and ‘over Time’, 1930s–1980s.” Business History Online. 20 Mar. 2024 <https://doi.org/10.1080/00076791.2023.2215193>. Golgowski, Nina. “Bones So Frail It Would Be Impossible to Walk and Room for Only Half a Liver: Shocking Research Reveals What Life Would Be Like If a REAL Woman Had Barbie's body.” Daily Mirror, 14 Apr. 2013. 19 Mar. 2024 <https://www.dailymail.co.uk/news/article-2308658/How-Barbies-body-size-look-real-life-Walking-fours-missing-half-liver-inches-intestine.html>. Green, Michelle, and Denise Gellene. “As a Tiny Plastic Star Turns 30, the Real Barbie and Ken Reflect on Life in the Shadow of the Dolls.” People, 6 Mar. 1989. 15 Mar. 2024 <https://people.com/archive/as-a-tiny-plastic-star-turns-30-the-real-barbie-and-ken-reflect-on-life-in-the-shadow-of-the-dolls-vol-31-no-9/>. Jones, Alexis. “Barbie's New 'Women in Sports' Dolls Are a Major Win For Athletes and Fans.” Popsugar, 9 Aug. 2023. 17 Mar. 2024 <https://www.popsugar.com/family/mattel-women-in-sports-barbie-49268194>. Lafond, Hannah. “How Barbies Have Changed over the Years.” The List, 7 Jul. 2023. 16 Mar. 2024 <https://www.thelist.com/1333916/barbies-changed-over-the-years/>. Lopez, Sandra. “10 Barbie Dolls Inspired by Real-Life Iconic Latinas.” Remezcla, 19 Jul. 2023. 20 Mar. 2024 <https://remezcla.com/lists/culture/barbie-dolls-inspired-by-real-life-iconic-latinas/>. Military Women’s Memorial. “Barbie Enlists.” 15 Mar. 2024 <https://womensmemorial.org/curators-corner/barbie-enlists/>. Moore, Hannah. “Why Warhol Painted Barbie.” BBC, 1 Oct. 2015. 15 Mar. 2024 <https://www.bbc.com/news/magazine-34407991>. Mowbray, Nicole. “Dressing Barbie: Meet the Designer Who Created a Miniature Fashion Icon.” CNN, 14 Jul. 2023. 17 Mar. 2024 <https://edition.cnn.com/style/dressing-barbie-iconic-fashion-looks>. New York Times. “Mattel Says It Erred; Teen Talk Barbie Turns Silent on Math." 21 Oct. 1992. 20 Mar. 2024 <https://www.nytimes.com/1992/10/21/business/company-news-mattel-says-it-erred-teen-talk-barbie-turns-silent-on-math.html>. Norton, Kevin, et al. “Ken and Barbie at Life Size.” Sex Roles 34 (1996): 287-294. https://doi.org/10.1007/BF01544300. Reinhard, Abby. “Here's How Much Your Childhood Barbies Are Really Worth Now, New Data Shows.” Best Life, 14 Jul. 2023. 15 Mar. 2024 <https://bestlifeonline.com/how-much-are-barbies-worth-now-news/>. Rice, Karlie, et al. “Exposure to Barbie: Effects on Thin-Ideal Internalisation, Body Esteem, and Body Dissatisfaction among Young Girls.” Body Image 19 (2016): 142-149. https://doi.org/10.1016/j.bodyim.2016.09.005. Rogers, Mary, F. Barbie Culture. Sage, 1999. Siazon, Kevin John. “The New 2019 Barbie Fashionistas Are More Diverse than Ever.” Today’s Parents, 12 Feb. 2019. 19 Mar. 2024 <https://www.todaysparent.com/blogs/trending/the-new-2019-barbie-fashionistas-are-more-diverse-than-ever/>. Sicard. Sarah. “A Few Good Dolls: Barbie Has Served in Every Military Branch.” Military Times, 28 Jul. 2023. 15 Mar. 2024 <https://www.militarytimes.com/off-duty/military-culture/2023/07/27/a-few-good-dolls-barbie-has-served-in-every-military-branch/>. Slayen, Galia. “The Scary Reality of a Real-Life Barbie Doll.” Huffington Post, 8 Apr. 2011. 19 Mar. 2024 <https://www.huffpost.com/entry/the-scary-reality-of-a-re_b_845239>. Southwell, Haxel. “Plastic on Track: Barbie's History in Motorsport”. Road and Track, 21 Jul. 2023. 15 Mar. 2024 <https://www.roadandtrack.com/car-culture/a44588941/plastic-on-track-barbie-history-in-motorsport/>. Statista. “Gross Sales of Mattel's Barbie Brand Worldwide from 2012 to 2022.” 2023. 16 Mar. 2024 <https://www.statista.com/statistics/370361/gross-sales-of-mattel-s-barbie-brand/>. ———. “Highest-Grossing Movies of All Time as of 2024.” 2024. 31 May 2024 <https://www.statista.com/statistics/262926/box-office-revenue-of-the-most-successful-movies-of-all-time/>. Stillwell, Blake. “Barbie and Ken Went to War Long before the 'Barbie' Movie.” Military.com, 26 Jul. 2023. 15 Mar. 2024 <https://www.military.com/off-duty/movies/2023/07/26/barbie-and-ken-went-war-long-barbie-movie.html>. Tamkin, Emily. Cultural History of Barbie.” Smithsonian, 23 Jun. 2023. 17 Mar. 2024 <https://www.smithsonianmag.com/arts-culture/cultural-history-barbie-180982115/>. Thong, Hang. “Barbie’s Doll Dimensions.” OmniSize, 29 Nov. 2023. 19 Mar. 2024 <https://omnisizes.com/hobbies/barbie-doll/>. Vander Bent, Emily. “The Evolution of Barbie: A Marker for Women’s History.” Girl Museum, 12 Apr. 2021. 16 Mar. 2024 <https://www.girlmuseum.org/the-evolution-of-barbie-a-marker-for-womens-history/>. Westenhouser, Kitturah B. The Story of Barbie. Collector Books, 1994. Wong, Bryan. “Daniel Wu Slams Barbie Maker Mattel for Stereotyping Asians as ‘Panda Doctors’ and ‘Violinists.’” Today Online, 24 Jan. 2024. 16 Mar. 2024 <https://www.todayonline.com/8days/daniel-wu-slams-barbie-maker-mattel-stereotyping-asians-panda-doctors-and-violinists-2347786>.

Introduction Ngarrindjeri futures depend on the survival of the land, waters, and other interconnected living things. The Murray-Darling Basin is recognised nationally and internationally as a system under stress. Ngarrindjeri have long understood the profound and intricate connection of land, water, humans, and non-humans (Trevorrow and Hemming). In an effort to secure environmental sustainability the Ngarrindjeri Regional Authority (NRA) have engaged in political negotiations with the State, primarily with the Department of Environment and Natural Resources (DENR), to transform natural resource management arrangements that engage with an ethics of justice, redistribution, and recognition (Hattam, Rigney and Hemming). In 1987, prior to the formation of the NRA, Camp Coorong: Race Relations and Cultural Education Centre was established by the Ngarrindjeri Lands and Progress Association in partnership with the South Australian Museum and the South Australian Education Department (Hemming) as a place for all citizens to engage with the values of a land ethic of care. The complex includes a cultural museum, accommodation, conference facilities, and workshop facilities for primary, secondary, and tertiary education students; it also serves as a base for research and course development on Indigenous and Ngarrindjeri culture and history (Hattam, Rigney and Hemming). Camp Coorong seeks to share Ngarrindjeri cultural values, knowledges, and histories with students and visitors in order to “improve relations between Aboriginal and non-Aboriginal people with a broader strategy aimed at securing a future for themselves in their own ‘Country’” (Hemming 37). The Centre is adjacent to the Coorong National Park and 200 km South-East of Adelaide. The establishment of Camp Coorong on Ngarrindjeri Ruwe/Ruwar (land/body/spirit) occurred when Ngarrindjeri Elders negotiated with the Department of Education and Children’s Services (DECS) to establish the race relations and cultural education centre. This negotiation was the beginning of many subsequent negotiations between Ngarrindjeri, local, State, and Federal governments about reclaiming ownership, management, and control of Ngarrindjeri lands, waters, and knowledge systems for a healthy Country and by implication healthy people (Hemming, Trevorrow and Rigney). As Elder Tom Trevorrow states: The waters and the seas, the waters of the Kurangh (Coorong), the waters of the rivers and lakes are all spiritual waters…The land and waters is a living body…We the Ngarrindjeri people are a part of its existence…The land and waters must be healthy for the Ngarrindjeri people to be healthy…We say that if Yarluwar-Ruwe dies, the water dies, our Ngartjis die, the Ngarrindjeri will surely die (Ngarrindjeri Nation Yarluwar-Ruwe Plan 13). Ruwe/Ruwar is an important aspect of the public pedagogy practiced at Camp Coorong and by the Ngarrindjeri Regional Authority (NRA). The NRA’s nation building activities arise from negotiated contractual agreements called KNYs: Kungan Ngarrindjeri Yunnan (Listen to Ngarrindjeri people talking). KNYs establish a vital aspect of the NRA’s strategic platform for political negotiations. However, the focus of this paper is concerned with local Indigenous experience of teaching and experience with the education system rather than the broader Ngarrindjeri educational objectives in the area. The specific concerns of this paper are the performance of storytelling and the dialectic relationship between the listener/learner (Tur and Tur). The pedagogy and place of Camp Coorong seeks to engage non-Indigenous people with Indigenous epistemologies through storytelling as a pedagogy of experience and a “pedagogy of discomfort” (Boler and Zembylas). Before detailing the relationship of these with one another, it is necessary to grasp the importance of the interconnectedness of Ruwe/Ruwar articulated in the opening statement of Ngarrindjeri Nations Yarluwar-Ruwe Plan: Caring for Ngarrindjeri Sea, Country and Culture: Our Lands, Our Waters, Our People, All Living Things are connected. We implore people to respect our Ruwe (Country) as it was created in the Kaldowinyeri (the Creation). We long for sparkling, clean waters, healthy land and people and all living things. We long for the Yarluwar-Ruwe (Sea Country) of our ancestors. Our vision is all people Caring, Sharing, Knowing and Respecting the lands, the waters, and all living things. Caring for Country The Lakes and the Coorong are dying as irrigation, over grazing, and pollution have left their toll on the Murray-Darling Basin. Camp Coorong delivers a key message (Hemming, 38) concerning the on-going obligation of Ngarrindjeri’s Ruwe/Ruwar to heal damaged sites both emotionally and environmentally. Couched as a civic responsibility, caring for County augments environmental action. However, there are epistemological distinctions between Natural Resources Management and Ngarrindjeri Ruwe/Ruwar. Ngarrindjeri conceive of the River Murray as one system that cannot be demarcated along state lines. Ngarrrindjeri Elder Uncle Matt Rigney, who recently passed away, argued that the River Murray and the Darling is embodied and that when the river is sick it impacts directly on Ngarrindjeri personhood and wellbeing (Hemming, Trevorrow and Rigney). Therefore, Ngarrindjeri have a responsibility to care for Ngarrindjeri Country and Ngarrindjeri governance systems are informed by cultural and ethical obligations to Ruwe/Ruwar of the lower Murray River, Lakes and Coorong. Transmitting knowledge of Country is imperative as Aunty Ellen Trevorrow states: We have to keep our culture alive. We want access to our special places, our lands and our waters. We need to be able to protect our places, our ngatji [totems], our Old People and restore damaged sites. We want respect for our land and our water and we want to pass down knowledge (cited in Bell, Women and Indigenous Religions 3). Ruwe/Ruwar is an ethic of care where men and women hold distinctive cultural and environmental knowledge and are responsible for passing knowledge to future generations. Knowledge is not codified into a “canon” but is “living knowledge” connected to how to live and how to understand the connection between material, spiritual, human, and non-human realms. Elders at Camp Coorong facilitate understandings of this ontology by sharing stories that evoke questions in children and adults alike. For settler Australians, the first phase of this understanding begins with an engagement with the discomfort of the colonial history of Indigenous dispossession. It also requires learning new modes of “re/inhabition” through a pedagogy informed by “place-consciousness” that centralises Indigenous connection to Country (Gruenewald Both Worlds). Many settler communities embody a dualist western epistemology that is necessarily disrupted when there is acknowledgment from whence one came (Carter 2009). The activities and stories at Camp Coorong provide a positive transformative pedagogy that transforms a possessive white logic (Moreton-Robinson) to one of shared cultural heritage. Ngarrindjeri epistemologies of connection to Country are expressed through a pedagogy of storytelling at Camp Coorong. This often occurs during weaving, making feather flowers, or walking on Ngarrindjeri Country with visitors and students. Enactments such as weaving are not simply occupational or functional. Weaving has deep cultural and metaphorical significance as Aunty Ellen Trevorrow states: There is a whole ritual in weaving. From where we actually start, the centre part of a piece, you’re creating loops to weave into, then you move into the circle. You keep going round and round creating the loops and once the children do those stages they’re talking, actually having a conversation, just like our Old People. It’s sharing time. And that’s where our stories were told (cited in Bell, Ngarrindjeri Wurruwarrin 44). At Camp Coorong learning involves listening to stories while engaging with activities such as weaving or walking on Country. The ecological changes and the history of dispossession are woven into narrative on Country and students see the impact of the desecration of the Coorong, Lower Murray and Lakes and lands. In this way the relatively recent history of colonial race relations and contemporary struggles with government bureaucracies and legislation also comprise the warp and weave of Ngarrindjeri knowledge and connection to Country. Pedagogy of Experience A pedagogy of experience involves telling the story of Indigenous peoples’ sense of “placelessness” within the nation (Watson) as a story of survival and resistance. It is through such pedagogies that Ngarrindjeri Elders at Camp Coorong reconstruct their lives and create agency in the face of settler colonialism. The experiences of growing up in Australia during the assimilation era, fighting against the State on policies that endorsed child theft, being forced to live at fringe camps, experiencing violent racisms, and, for some, living as part of a diaspora in one’s own Country is embedded in the stories of survival, resilience and agency. “Camp Coorong began as an experiment in alternative teaching methods developed largely by George Trevorrow, a local Ngarrindjeri man” (Hemming 38). Classroom malaise was experienced by Ngarrindjeri Elders from Camp Coorong, such as Uncle Tom and Aunty Ellen Trevorrow and the late Uncle George Trevorrow, Aunty Alice Abdulla, and others when interacting or employed in schools as Aboriginal Education Workers (AEWs). It was the invisibility of these Elders’ knowledges inside schools that generated the impetus to establish Camp Coorong as a counter-institution. The spatial dimension of situationality, and its attention to social transformation, connects critical pedagogy to a pedagogy of place at Camp Coorong. Both discourses are concerned with the contextual, geographical conditions that shape people, and the actions people take to shape these conditions (Gruenewald, Both Worlds). Place-based education at Camp Coorong advocates a new localism in order to stimulate community revitalisation and resistance to globalisation and commodity capitalism. It provides the space and opportunity to develop the capacity for inventiveness and adaptation to changing environments and resistance to ecological destruction. Of concern to the growing field of place-based education are how to promote care for people and places (Gruenewald and Smith, xix). For Gruenewald and Smith this requires decolonisation and developing sensitivity to forms of thought that injure and exploit people and places, and re/inhabitation by identifying, conserving, and creating knowledge that nurtures and protects people and places. Engaging in a land ethic of care on Country informs the educational paradigm at Camp Coorong that does not begin in front of bulldozers or under police batons at anti-globalisation rallies, but in the contact zones (Somerville 342) where “a material and metaphysical in-between space for the intersection of multiple and contested stories” (Somerville 342) emerge. Ngarrindjeri knowledge, environmental knowledge, scientific knowledge, colonial histories, and media representations all circulate in the contact zone and are held in productive tension (Carter). Decolonising Pedagogy and Pedagogies of Discomfort The critical and transformative aspects of decolonising pedagogies emerge from storytelling and involve the gift of narrative and the enactment of reciprocity that occurs between the listener and the storyteller. Reciprocity is based on the principles of interconnectedness, balance, and the idea that actions create corresponding action through the gift of story (Stewart-Harawira). Camp Coorong is a place for inter-cultural dialogue through storytelling. Being located on Ngarrindjeri Country the non-Indigenous listener is more able to “hear” and at the same time move along a continuum of a) disbelief and anger about the dispossession of Indigenous peoples; b) emotional confusion about their own sense of belonging in Australia; c) shock at the ways in which liberal western society’s structural privilege is built on Indigenous inequality on the grounds of race and habitus (Bordieu and Passeron); then, d) towards empathy that is framed as race cognisance (Aveling). Stories are not represented through a sanguine vision of the past, but are told of colonisation, dispossession, as well as of hope for the healing of Ngarrinjderi Country. The listener is gifted with stories at Camp Coorong. However, there is an ethical obligation to the gifting that learners may not understand until later and which concern the rights and obligations fundamental to notions of deep connection to Country. It is often in the recount of one’s experience at Camp Coorong, such as in reflective journals or in conversation, that recognition of the importance of history, social justice, and sovereignty are brought to light. In the first phase of learning, non-Indigenous students and teachers may move from uncomfortable silence, to a space where they can hear the stories and thereby become engaged listeners. They may go through a process of grappling with a range of issues and emotions. There is frustration, anger, and blame that knowledge has been omitted from their education, and they routinely ask: “How did we not know this history?” In the second stage learners tend to remain outside of the story until they are hooked by an aspect that draws them into it. They have the choice of engagement and this requires empathy. At this stage learners are grappling with the antithetical feelings of guilt and innocence; these feelings emerge when those advantaged and challenged by their complicity with settler colonialism, racism, and the structural privilege of whiteness start to understand the benefits they gain from Indigenous dispossession and ask “was it my fault?” Thirdly, learners enter a space which may disavow and dismiss the newly encountered knowledge and move back into resistance, silence, and reluctance to hear. However, it is at this point that a choice emerges. The choice to engage in the emotional labour required to acknowledge the gift of the story and thereby unsettle white Australian identity (Bignall; Boler and Zembylas). In this process “inscribed habits of attention,” as described by Boler and Zembylas (127), are challenged. These habits have been enabled by the emotional binaries of “us” and “them”. The colonial legacy of Indigenous dispossession is an emotive subject that disrupts national pride that is built on this binary. At Camp Coorong, discomfort is created during the reiteration of stories and engagement in various activities. Uncertainty and discomfort are necessary parts of restructuring the emotional habitus and reconstructing identity. The primary ethical aim of a pedagogy of discomfort is the creation of contestability. The learner comes to understand the rights and obligations of caring for Country and has to decide how to carry the story. Ngarrindjeri ethics of care inspire the learner to undertake the emotional labour necessary to relocate their understanding of identity. As a zone of cultural contestation, Camp Coorong also enables pedagogies that allow for critical reflection on common educational practices undertaken by educators and students. Conclusion The aim of the camp was to overturn racism and provide employment for Ngarrindjeri on Country (Hemming, 38). Students and teachers from around the state come to Camp Coorong and learn to weave, make feather flowers, and listen to stories about Ngarrindjeri Country whilst walking on Country (Hemming 38). Camp Coorong fosters understanding of Ngarrindjeri Ruwe/Ruwar and at the same time overturns essentialist notions developed by deficit theories that routinely remain embedded in the school curriculum. Camp Coorong’s anti-racist epistemology mobilises an Indigenous pedagogy of storytelling and experience as a decolonising methodology. Learning Ngarrindjeri history, cultural heritage, and land ethic of care deepens students’ understanding of connecting to Country through reflection on situations, histories, and shared spaces of human and non-human actors. Pedagogies of discomfort also inform practice at Camp Coorong and the intersections of theory and practice in this context disrupts identity formations that have been grounded in a white colonial construction of nationhood. Education is a means of social and cultural reproduction, as well as a key site of resistance and vehicle for social change. Although the analysis of domination is a feature of critical pedagogy, what is urgently required is a language of hope and transformation understood from a Ngarrindjeri standpoint; something that is achieved at Camp Coorong. Acknowledgments I would like to acknowledge the process of collaboration that occurred at Camp Coorong with Aunty Ellen Trevorrow, Aunty Alice Abdulla, and Deborah Rankine. The key ideas were established in conversation and the article was revised on subsequent occasions whilst at Camp Coorong with the aforementioned authors. This paper was produced as part of the Australian Research Council Discovery Project, ‘Negotiating a Space in the Nation: The Case of Ngarrindjeri’ (DP1094869). The Chief Investigators are Robert Hattam, Peter Bishop, Pal Ahluwalia, Julie Matthews, Daryle Rigney, Steve Hemming and Robin Boast, working with Simone Bignall and Bindi MacGill. References Aveling, Nado. “Critical whiteness studies and the challenges of learning to be a 'White Ally'.” Borderlands e-journal 3. 2 (2004). 12 Dec 2006 ‹www.borderlandsejournal.adelaide.edu.au› Bell, Diane. Ngarrindjeri Wurruwarrin: A World That Is, Was, and Will Be. North Melbourne: Spinifex Press, 1998. ——-. Kungun Ngarrindjeri Miminar Yunnan. Listen to Ngarrindjeri Women Speaking. Melbourne: Spinifex, 2008. ——-. “Ngarrindjeri Women’s Stories: Kungun and Yunnan.” Women and Indigenous Religions. Ed. Sylvia Marcos. California: Greenwood, 2010: 3-20. Bignall, Simone. Postcolonial Agency: Critique and Constructivism. Edinburgh: Edinburgh University Press, 2010. Boler, Megan and Michalinos Zembylas. “Discomforting Truths: The Emotional Terrain of Understanding Difference.” Pedagogies of Difference: Rethinking Education for Social Change. Ed. P. Trifonas. New York: Routledge Falmer, 2003: 110-36. Bourdieu, Pierre and Jean-Claude Passeron. Reproduction in Education, Society and Culture. London: Sage Publications, 1990. Carter, Paul. “Care at a Distance: Affiliations to Country in a Global Context.” Lanscapes and learning. Place Studies for a Global Village. Ed. Margaret. Somerville, Kerith Power and Phoenix de Carteret. Rotterdam: Sense. 2, 2009. 1-33. Gruenewald, David. “The Best of Both Worlds: A Critical Pedagogy of Place.” Educational Researcher 43.4 (2003): 3-12. ——-. “Foundations of Place: A Multidisciplinary Framework for Place-Conscious Education.” American Educational Research Journal, 40.3 (2003): 619-54. Gruenewald, David and Gregory Smith. “Making Room for the Local.” Place-Based Education in the Global Age: Local Diversity. Ed. David Gruenewald & Gregory Smith. New York: Lawrence Erlbaum Associates, 2008. Hattam, Rob., Daryle Rigney and Steve Hemming. “Reconciliation? Culture and Nature and the Murray River.” Fresh Water: New Perspectives on Water in Australia. Ed. Emily Potter, Alison Mackinnon, McKenzie, Stephen & Jenny McKay. Carlton: Melbourne University Press, 2007:105-22. Hemming, Steve., Tom Trevorrow and Matt, Rigney. “Ngarrindjeri Culture.” The Murray Mouth: Exploring the Implications of Closure or Restricted Flow. Ed. M Goodwin and S Bennett. Department of Water, Land and Biodiversity Conservation, Adelaide (2002): 13–19. Hemming, Steve. “Camp Coorong—Combining Race Relations and Cultural Education.” Social Alternatives 12.1 (1993): 37-40. MacGill, Bindi. Aboriginal Education Workers: Towards Equality of Recognition of Indigenous Ethics of Care Practices in South Australian School (Unpublished doctoral dissertation). Adelaide: Finders University, 2008. Stewart-Harawira, Makere. “Cultural Studies, Indigenous Knowledge and Pedagogies of Hope.” Policy Futures in Education 3.2 (2005):153-63. Moreton-Robinson, Aileen. “The Possessive Logic of Patriarchal White Sovereignty: the High Court and the Yorta Yorta Decision.” Taking up the Challenge: Critical Whiteness Studies in a Postcolonising Nation. Ed. Damien Riggs. Belair: Crawford House, 2007:109-24. Ngarrindjeri Nation. Ngarrindjeri Nation Yarluwar-Ruwe Plan: Caring for Ngarrindjeri Sea Country and Culture. Ngarrindjeri Tendi, Ngarrindjeri Heritage Committee, Ngarrindjeri Native Title Management Committee. Camp Coorong: Ngarrindjeri Land and Progress Association, 2006. Somerville, Margaret. “A Place Pedagogy for ‘Global Contemporaneity.” Educational Philosophy and Theory 42 (2010): 326–44. Trevorrow, Tom and Steve Hemming. “Conversation: Kunggun Ngarrindjeri Yunnan, Listen to Ngarrindjeri People Talking”. Sharing Spaces, Indigenous and Non-Indigenous Responses, to Story, Country and Rights. Ed. Gus Worby and. Lester Irabinna Rigney. Perth: API Network, 2006. 295-304. Tur, Mona & Simone Tur. “Conversation: Wapar munu Mamtali Nintiringanyi-Learning about the Dreaming and Land.” Sharing Spaces, Indigenous and Non-Indigenous Responses, to Story, Country and Rights. Ed. Gus Worby and. Lester Irabinna Rigney. Perth: API Network, 2006: 160-70. Watson, Irene. "Sovereign Spaces, Caring for Country, and the Homeless Position of Aboriginal Peoples." South Atlantic Quaterly 108.1 (2009): 27-51.

Introduction: Technology EnthusiasmEnthusiasts are people who have a passion, keenness, dedication or zeal for a particular activity or hobby. Today, there are enthusiasts for almost everything, from genealogy, costume dramas, and country houses, to metal detectors, coin collecting, and archaeology. But to be described as an enthusiast is not necessarily a compliment. Historically, the term “enthusiasm” was first used in England in the early seventeenth century to describe “religious or prophetic frenzy among the ancient Greeks” (Hanks, n.p.). This frenzy was ascribed to being possessed by spirits sent not only by God but also the devil. During this period, those who disobeyed the powers that be or claimed to have a message from God were considered to be enthusiasts (McLoughlin).Enthusiasm retained its religious connotations throughout the eighteenth century and was also used at this time to describe “the tendency within the population to be swept by crazes” (Mee 31). However, as part of the “rehabilitation of enthusiasm,” the emerging middle-classes adopted the word to characterise the intensity of Romantic poetry. The language of enthusiasm was then used to describe the “literary ideas of affect” and “a private feeling of religious warmth” (Mee 2 and 34). While the notion of enthusiasm was embraced here in a more optimistic sense, attempts to disassociate enthusiasm from crowd-inciting fanaticism were largely unsuccessful. As such enthusiasm has never quite managed to shake off its pejorative connotations.The 'enthusiasm' discussed in this paper is essentially a personal passion for technology. It forms part of a longer tradition of historical preservation in the United Kingdom and elsewhere in the world. From preserved railways to Victorian pumping stations, people have long been fascinated by the history of technology and engineering; manifesting their enthusiasm through their nostalgic longings and emotional attachment to its enduring material culture. Moreover, enthusiasts have been central to the collection, conservation, and preservation of this particular material record. Technology enthusiasm in this instance is about having a passion for the history and material record of technological development, specifically here industrial archaeology. Despite being a pastime much participated in, technology enthusiasm is relatively under-explored within the academic literature. For the most part, scholarship has tended to focus on the intended users, formal spaces, and official narratives of science and technology (Adas, Latour, Mellström, Oldenziel). In recent years attempts have been made to remedy this imbalance, with researchers from across the social sciences examining the position of hobbyists, tinkerers and amateurs in scientific and technical culture (Ellis and Waterton, Haring, Saarikoski, Takahashi). Work from historians of technology has focussed on the computer enthusiast; for example, Saarikoski’s work on the Finnish personal computer hobby:The definition of the computer enthusiast varies historically. Personal interest, pleasure and entertainment are the most significant factors defining computing as a hobby. Despite this, the hobby may also lead to acquiring useful knowledge, skills or experience of information technology. Most often the activity takes place outside working hours but can still have links to the development of professional expertise or the pursuit of studies. In many cases it takes place in the home environment. On the other hand, it is characteristically social, and the importance of friends, clubs and other communities is greatly emphasised.In common with a number of other studies relating to technical hobbies, for example Takahashi who argues tinkerers were behind the advent of the radio and television receiver, Saarikoski’s work focuses on the role these users played in shaping the technology in question. The enthusiasts encountered in this paper are important here not for their role in shaping the technology, but keeping technological heritage alive. As historian of technology Haring reminds us, “there exist alternative ways of using and relating to technology” (18). Furthermore, the sociological literature on audiences (Abercrombie and Longhurst, Ang), fans (Hills, Jenkins, Lewis, Sandvoss) and subcultures (Hall, Hebdige, Schouten and McAlexander) has also been extended in order to account for the enthusiast. In Abercrombie and Longhurst’s Audiences, the authors locate ‘the enthusiast’ and ‘the fan’ at opposing ends of a continuum of consumption defined by questions of specialisation of interest, social organisation of interest and material productivity. Fans are described as:skilled or competent in different modes of production and consumption; active in their interactions with texts and in their production of new texts; and communal in that they construct different communities based on their links to the programmes they like. (127 emphasis in original) Based on this definition, Abercrombie and Longhurst argue that fans and enthusiasts differ in three ways: (1) enthusiasts’ activities are not based around media images and stars in the way that fans’ activities are; (2) enthusiasts can be hypothesized to be relatively light media users, particularly perhaps broadcast media, though they may be heavy users of the specialist publications which are directed towards the enthusiasm itself; (3) the enthusiasm would appear to be rather more organised than the fan activity. (132) What is striking about this attempt to differentiate between the fan and the enthusiast is that it is based on supposition rather than the actual experience and observation of enthusiasm. It is here that the ethnographic account of enthusiasm presented in this paper and elsewhere, for example works by Dannefer on vintage car culture, Moorhouse on American hot-rodding and Fuller on modified-car culture in Australia, can shed light on the subject. My own ethnographic study of groups with a passion for telecommunications heritage, early British computers and industrial archaeology takes the discussion of “technology enthusiasm” further still. Through in-depth interviews, observation and textual analysis, I have examined in detail the formation of enthusiast societies and their membership, the importance of the material record to enthusiasts (particularly at home) and the enthusiastic practices of collecting and hoarding, as well as the figure of the technology enthusiast in the public space of the museum, namely the Science Museum in London (Geoghegan). In this paper, I explore the culture of enthusiasm for the industrial past through the example of the Greater London Industrial Archaeology Society (GLIAS). Focusing on industrial sites around London, GLIAS meet five or six times a year for field visits, walks and a treasure hunt. The committee maintain a website and produce a quarterly newsletter. The title of my paper, “If you can walk down the street and recognise the difference between cast iron and wrought iron, the world is altogether a better place,” comes from an interview I conducted with the co-founder and present chairman of GLIAS. He was telling me about his fascination with the materials of industrialisation. In fact, he said even concrete is sexy. Some call it a hobby; others call it a disease. But enthusiasm for industrial archaeology is, as several respondents have themselves identified, “as insidious in its side effects as any debilitating germ. It dictates your lifestyle, organises your activity and decides who your friends are” (Frow and Frow 177, Gillespie et al.). Through the figure of the industrial archaeology enthusiast, I discuss in this paper what it means to be enthusiastic. I begin by reflecting on the development of this specialist subject area. I go on to detail the formation of the Society in the late 1960s, before exploring the Society’s fieldwork methods and some of the other activities they now engage in. I raise questions of enthusiast and professional knowledge and practice, as well as consider the future of this particular enthusiasm.Defining Industrial ArchaeologyThe practice of 'industrial archaeology' is much contested. For a long time, enthusiasts and professional archaeologists have debated the meaning and use of the term (Palmer). On the one hand, there are those interested in the history, preservation, and recording of industrial sites. For example the grandfather figures of the subject, namely Kenneth Hudson and Angus Buchanan, who both published widely in the 1960s and 1970s in order to encourage publics to get involved in recording. Many members of GLIAS refer to the books of Hudson Industrial Archaeology: an Introduction and Buchanan Industrial Archaeology in Britain with their fine descriptions and photographs as integral to their early interest in the subject. On the other hand, there are those within the academic discipline of archaeology who consider the study of remains produced by the Industrial Revolution as too modern. Moreover, they find the activities of those calling themselves industrial archaeologists as lacking sufficient attention to the understanding of past human activity to justify the name. As a result, the definition of 'industrial archaeology' is problematic for both enthusiasts and professionals. Even the early advocates of professional industrial archaeology felt uneasy about the subject’s methods and practices. In 1973, Philip Riden (described by one GLIAS member as the angry young man of industrial archaeology), the then president of the Oxford University Archaeology Society, wrote a damning article in Antiquity, calling for the subject to “shed the amateur train drivers and others who are not part of archaeology” (215-216). He decried the “appallingly low standard of some of the work done under the name of ‘industrial archaeology’” (211). He felt that if enthusiasts did not attempt to maintain high technical standards, publish their work in journals or back up their fieldwork with documentary investigation or join their county archaeological societies then there was no value in the efforts of these amateurs. During this period, enthusiasts, academics, and professionals were divided. What was wrong with doing something for the pleasure it provides the participant?Although relations today between the so-called amateur (enthusiast) and professional archaeologies are less potent, some prejudice remains. Describing them as “barrow boys”, some enthusiasts suggest that what was once their much-loved pastime has been “hijacked” by professional archaeologists who, according to one respondent,are desperate to find subjects to get degrees in. So the whole thing has been hijacked by academia as it were. Traditional professional archaeologists in London at least are running head on into things that we have been doing for decades and they still don’t appreciate that this is what we do. A lot of assessments are handed out to professional archaeology teams who don’t necessarily have any knowledge of industrial archaeology. (James, GLIAS committee member)James went on to reveal that GLIAS receives numerous enquiries from professional archaeologists, developers and town planners asking what they know about particular sites across the city. Although the Society has compiled a detailed database covering some areas of London, it is by no means comprehensive. In addition, many active members often record and monitor sites in London for their own personal enjoyment. This leaves many questioning the need to publish their results for the gain of third parties. Canadian sociologist Stebbins discusses this situation in his research on “serious leisure”. He has worked extensively with amateur archaeologists in order to understand their approach to their leisure activity. He argues that amateurs are “neither dabblers who approach the activity with little commitment or seriousness, nor professionals who make a living from that activity” (55). Rather they pursue their chosen leisure activity to professional standards. A point echoed by Fine in his study of the cultures of mushrooming. But this is to get ahead of myself. How did GLIAS begin?GLIAS: The GroupThe 1960s have been described by respondents as a frantic period of “running around like headless chickens.” Enthusiasts of London’s industrial archaeology were witnessing incredible changes to the city’s industrial landscape. Individuals and groups like the Thames Basin Archaeology Observers Group were recording what they could. Dashing around London taking photos to capture London’s industrial legacy before it was lost forever. However the final straw for many, in London at least, was the proposed and subsequent demolition of the “Euston Arch”. The Doric portico at Euston Station was completed in 1838 and stood as a symbol to the glory of railway travel. Despite strong protests from amenity societies, this Victorian symbol of progress was finally pulled down by British Railways in 1962 in order to make way for what enthusiasts have called a “monstrous concrete box”.In response to these changes, GLIAS was founded in 1968 by two engineers and a locomotive driver over afternoon tea in a suburban living room in Woodford, North-East London. They held their first meeting one Sunday afternoon in December at the Science Museum in London and attracted over 130 people. Firing the imagination of potential members with an exhibition of photographs of the industrial landscape taken by Eric de Maré, GLIAS’s first meeting was a success. Bringing together like-minded people who are motivated and enthusiastic about the subject, GLIAS currently has over 600 members in the London area and beyond. This makes it the largest industrial archaeology society in the UK and perhaps Europe. Drawing some of its membership from a series of evening classes hosted by various members of the Society’s committee, GLIAS initially had a quasi-academic approach. Although some preferred the hands-on practical element and were more, as has been described by one respondent, “your free-range enthusiast”. The society has an active committee, produces a newsletter and journal, as well as runs regular events for members. However the Society is not simply about the study of London’s industrial heritage, over time the interest in industrial archaeology has developed for some members into long-term friendships. Sociability is central to organised leisure activities. It underpins and supports the performance of enthusiasm in groups and societies. For Fine, sociability does not always equal friendship, but it is the state from which people might become friends. Some GLIAS members have taken this one step further: there have even been a couple of marriages. Although not the subject of my paper, technical culture is heavily gendered. Industrial archaeology is a rare exception attracting a mixture of male and female participants, usually retired husband and wife teams.Doing Industrial Archaeology: GLIAS’s Method and PracticeIn what has been described as GLIAS’s heyday, namely the 1970s to early 1980s, fieldwork was fundamental to the Society’s activities. The Society’s approach to fieldwork during this period was much the same as the one described by champion of industrial archaeology Arthur Raistrick in 1973:photographing, measuring, describing, and so far as possible documenting buildings, engines, machinery, lines of communication, still or recently in use, providing a satisfactory record for the future before the object may become obsolete or be demolished. (13)In the early years of GLIAS and thanks to the committed efforts of two active Society members, recording parties were organised for extended lunch hours and weekends. The majority of this early fieldwork took place at the St Katherine Docks. The Docks were constructed in the 1820s by Thomas Telford. They became home to the world’s greatest concentration of portable wealth. Here GLIAS members learnt and employed practical (also professional) skills, such as measuring, triangulations and use of a “dumpy level”. For many members this was an incredibly exciting time. It was a chance to gain hands-on experience of industrial archaeology. Having been left derelict for many years, the Docks have since been redeveloped as part of the Docklands regeneration project.At this time the Society was also compiling data for what has become known to members as “The GLIAS Book”. The book was to have separate chapters on the various industrial histories of London with contributions from Society members about specific sites. Sadly the book’s editor died and the project lost impetus. Several years ago, the committee managed to digitise the data collected for the book and began to compile a database. However, the GLIAS database has been beset by problems. Firstly, there are often questions of consistency and coherence. There is a standard datasheet for recording industrial buildings – the Index Record for Industrial Sites. However, the quality of each record is different because of the experience level of the different authors. Some authors are automatically identified as good or expert record keepers. Secondly, getting access to the database in order to upload the information has proved difficult. As one of the respondents put it: “like all computer babies [the creator of the database], is finding it hard to give birth” (Sally, GLIAS member). As we have learnt enthusiasm is integral to movements such as industrial archaeology – public historian Raphael Samuel described them as the “invisible hands” of historical enquiry. Yet, it is this very enthusiasm that has the potential to jeopardise projects such as the GLIAS book. Although active in their recording practices, the GLIAS book saga reflects one of the challenges encountered by enthusiast groups and societies. In common with other researchers studying amenity societies, such as Ellis and Waterton’s work with amateur naturalists, unlike the world of work where people are paid to complete a task and are therefore meant to have a singular sense of purpose, the activities of an enthusiast group like GLIAS rely on the goodwill of their members to volunteer their time, energy and expertise. When this is lost for whatever reason, there is no requirement for any other member to take up that position. As such, levels of commitment vary between enthusiasts and can lead to the aforementioned difficulties, such as disputes between group members, the occasional miscommunication of ideas and an over-enthusiasm for some parts of the task in hand. On top of this, GLIAS and societies like it are confronted with changing health and safety policies and tightened security surrounding industrial sites. This has made the practical side of industrial archaeology increasingly difficult. As GLIAS member Bob explains:For me to go on site now I have to wear site boots and borrow a hard hat and a high visibility jacket. Now we used to do incredibly dangerous things in the seventies and nobody batted an eyelid. You know we were exploring derelict buildings, which you are virtually not allowed in now because the floor might give way. Again the world has changed a lot there. GLIAS: TodayGLIAS members continue to record sites across London. Some members are currently surveying the site chosen as the location of the Olympic Games in London in 2012 – the Lower Lea Valley. They describe their activities at this site as “rescue archaeology”. GLIAS members are working against the clock and some important structures have already been demolished. They only have time to complete a quick flash survey. Armed with the information they collated in previous years, GLIAS is currently in discussions with the developer to orchestrate a detailed recording of the site. It is important to note here that GLIAS members are less interested in campaigning for the preservation of a site or building, they appreciate that sites must change. Instead they want to ensure that large swathes of industrial London are not lost without a trace. Some members regard this as their public duty.Restricted by health and safety mandates and access disputes, GLIAS has had to adapt. The majority of practical recording sessions have given way to guided walks in the summer and public lectures in the winter. Some respondents have identified a difference between those members who call themselves “industrial archaeologists” and those who are just “ordinary members” of GLIAS. The walks are for those with a general interest, not serious members, and the talks are public lectures. Some audience researchers have used Bourdieu’s metaphor of “capital” to describe the experience, knowledge and skill required to be a fan, clubber or enthusiast. For Hills, fan status is built up through the demonstration of cultural capital: “where fans share a common interest while also competing over fan knowledge, access to the object of fandom, and status” (46). A clear membership hierarchy can be seen within GLIAS based on levels of experience, knowledge and practical skill.With a membership of over 600 and rising annually, the Society’s future is secure at present. However some of the more serious members, although retaining their membership, are pursuing their enthusiasm elsewhere: through break-away recording groups in London; active membership of other groups and societies, for example the national Association for Industrial Archaeology; as well as heading off to North Wales in the summer for practical, hands-on industrial archaeology in Snowdonia’s slate quarries – described in the Ffestiniog Railway Journal as the “annual convention of slate nutters.” ConclusionsGLIAS has changed since its foundation in the late 1960s. Its operation has been complicated by questions of health and safety, site access, an ageing membership, and the constant changes to London’s industrial archaeology. Previously rejected by professional industrial archaeology as “limited in skill and resources” (Riden), enthusiasts are now approached by professional archaeologists, developers, planners and even museums that are interested in engaging in knowledge exchange programmes. As a recent report from the British think-tank Demos has argued, enthusiasts or pro-ams – “amateurs who work to professional standards” (Leadbeater and Miller 12) – are integral to future innovation and creativity; for example computer pro-ams developed an operating system to rival Microsoft Windows. As such the specialist knowledge, skill and practice of these communities is of increasing interest to policymakers, practitioners, and business. So, the subject once described as “the ugly offspring of two parents that shouldn’t have been allowed to breed” (Hudson), the so-called “amateur” industrial archaeology offers enthusiasts and professionals alike alternative ways of knowing, seeing and being in the recent and contemporary past.Through the case study of GLIAS, I have described what it means to be enthusiastic about industrial archaeology. I have introduced a culture of collective and individual participation and friendship based on a mutual interest in and emotional attachment to industrial sites. As we have learnt in this paper, enthusiasm is about fun, pleasure and joy. The enthusiastic culture presented here advances themes such as passion in relation to less obvious communities of knowing, skilled practices, material artefacts and spaces of knowledge. Moreover, this paper has been about the affective narratives that are sometimes missing from academic accounts; overlooked for fear of sniggers at the back of a conference hall. Laughter and humour are a large part of what enthusiasm is. Enthusiastic cultures then are about the pleasure and joy experienced in doing things. Enthusiasm is clearly a potent force for active participation. I will leave the last word to GLIAS member John:One meaning of enthusiasm is as a form of possession, madness. Obsession perhaps rather than possession, which I think is entirely true. It is a pejorative term probably. The railway enthusiast. But an awful lot of energy goes into what they do and achieve. Enthusiasm to my mind is an essential ingredient. If you are not a person who can muster enthusiasm, it is very difficult, I think, to get anything out of it. On the basis of the more you put in the more you get out. In terms of what has happened with industrial archaeology in this country, I think, enthusiasm is a very important aspect of it. The movement needs people who can transmit that enthusiasm. ReferencesAbercrombie, N., and B. Longhurst. Audiences: A Sociological Theory of Performance and Imagination. London: Sage Publications, 1998.Adas, M. Machines as the Measure of Men: Science, Technology and Ideologies of Western Dominance. Ithaca: Cornell UP, 1989.Ang, I. Desperately Seeking the Audience. London: Routledge, 1991.Bourdieu, P. Distinction: A Social Critique of the Judgement of Taste. London: Routledge, 1984.Buchanan, R.A. Industrial Archaeology in Britain. Harmondsworth, Middlesex: Penguin, 1972.Dannefer, D. “Rationality and Passion in Private Experience: Modern Consciousness and the Social World of Old-Car Collectors.” Social Problems 27 (1980): 392–412.Dannefer, D. “Neither Socialization nor Recruitment: The Avocational Careers of Old-Car Enthusiasts.” Social Forces 60 (1981): 395–413.Ellis, R., and C. Waterton. “Caught between the Cartographic and the Ethnographic Imagination: The Whereabouts of Amateurs, Professionals, and Nature in Knowing Biodiversity.” Environment and Planning D: Society and Space 23 (2005): 673–693.Fine, G.A. “Mobilizing Fun: Provisioning Resources in Leisure Worlds.” Sociology of Sport Journal 6 (1989): 319–334.Fine, G.A. Morel Tales: The Culture of Mushrooming. Champaign, Ill.: U of Illinois P, 2003.Frow, E., and R. Frow. “Travels with a Caravan.” History Workshop Journal 2 (1976): 177–182Fuller, G. Modified: Cars, Culture, and Event Mechanics. Unpublished PhD Thesis, University of Western Sydney, 2007.Geoghegan, H. The Culture of Enthusiasm: Technology, Collecting and Museums. Unpublished PhD Thesis, University of London, 2008.Gillespie, D.L., A. Leffler, and E. Lerner. “‘If It Weren’t for My Hobby, I’d Have a Life’: Dog Sports, Serious Leisure, and Boundary Negotiations.” Leisure Studies 21 (2002): 285–304.Hall, S., and T. Jefferson, eds. Resistance through Rituals: Youth Sub-Cultures in Post-War Britain. London: Hutchinson, 1976.Hanks, P. “Enthusiasm and Condescension.” Euralex ’98 Proceedings. 1998. 18 Jul. 2005 ‹http://www.patrickhanks.com/papers/enthusiasm.pdf›.Haring, K. “The ‘Freer Men’ of Ham Radio: How a Technical Hobby Provided Social and Spatial Distance.” Technology and Culture 44 (2003): 734–761.Haring, K. Ham Radio’s Technical Culture. London: MIT Press, 2007.Hebdige, D. Subculture: The Meaning of Style. London: Methuen, 1979.Hills, M. Fan Cultures. London: Routledge, 2002.Hudson, K. Industrial Archaeology London: John Baker, 1963.Jenkins, H. Textual Poachers: Television Fans and Participatory Culture. London: Routledge, 1992.Latour, B. Aramis, or the Love of Technology. London: Harvard UP, 1996.Leadbeater, C., and P. Miller. The Pro-Am Revolution: How Enthusiasts Are Changing Our Economy and Society. London: Demos, 2004.Lewis, L.A., ed. The Adoring Audience: Fan Culture and Popular Media. London: Routledge, 1992.McLoughlin, W.G. Revivals, Awakenings, and Reform: An Essay on Religion and Social Change in America, 1607-1977. London: U of Chicago P, 1977.Mee, J. Romanticism, Enthusiasm, and Regulation: Poetics and the Policing of Culture in the Romantic Period. Oxford: Oxford UP, 2003.Mellström, U. “Patriarchal Machines and Masculine Embodiment.” Science, Technology, & Human Values 27 (2002): 460–478.Moorhouse, H.F. Driving Ambitions: A Social Analysis of American Hot Rod Enthusiasm. Manchester: Manchester UP, 1991.Oldenziel, R. Making Technology Masculine: Men, Women and Modern Machines in America 1870-1945. Amsterdam: Amsterdam UP, 1999.Palmer, M. “‘We Have Not Factory Bell’: Domestic Textile Workers in the Nineteenth Century.” The Local Historian 34 (2004): 198–213.Raistrick, A. Industrial Archaeology. London: Granada, 1973.Riden, P. “Post-Post-Medieval Archaeology.” Antiquity XLVII (1973): 210-216.Rix, M. “Industrial Archaeology: Progress Report 1962.” The Amateur Historian 5 (1962): 56–60.Rix, M. Industrial Archaeology. London: The Historical Association, 1967.Saarikoski, P. The Lure of the Machine: The Personal Computer Interest in Finland from the 1970s to the Mid-1990s. Unpublished PhD Thesis, 2004. ‹http://users.utu.fi/petsaari/lure.pdf›.Samuel, R. Theatres of Memory London: Verso, 1994.Sandvoss, C. Fans: The Mirror of Consumption Cambridge: Polity, 2005.Schouten, J.W., and J. McAlexander. “Subcultures of Consumption: An Ethnography of the New Bikers.” Journal of Consumer Research 22 (1995) 43–61.Stebbins, R.A. Amateurs: On the Margin between Work and Leisure. Beverly Hills: Sage, 1979.Stebbins, R.A. Amateurs, Professionals, and Serious Leisure. London: McGill-Queen’s UP, 1992.Takahashi, Y. “A Network of Tinkerers: The Advent of the Radio and Television Receiver Industry in Japan.” Technology and Culture 41 (2000): 460–484.

The brand began, quite literally, as a method for ranchers to identify their cattle. By burning a distinct symbol into the hide of a baby calf, the owner could insure that if it one day wandered off his property or was stolen by a competitor, he’d be able to point to that logo and claim the animal as his rightful property. When the manufacturers of products adopted the brand as a way of guaranteeing the quality of their goods, its function remained pretty much the same. Buying a package of oats with the Quaker label meant the customer could trace back these otherwise generic oats to their source. If there was a problem, he knew where he could turn. More important, if the oats were of satisfactory or superior quality, he knew where he could get them again. Trademarking a brand meant that no one else could call his oats Quaker. Advertising in this innocent age simply meant publicizing the existence of one’s brand. The sole objective was to increase consumers awareness of the product or company that made it. Those who even thought to employ specialists for the exclusive purpose of writing ad copy hired newspaper reporters and travelling salesmen, who knew how to explain the attributes of an item in words that people tended to remember. It wasn’t until 1922 that a preacher and travelling “medicine show” salesman-turned-copywriter named Claude Hopkins decided that advertising should be systematized into a science. His short but groundbreaking book Scientific Advertising proposed that the advertisement is merely a printed extension of the salesman¹s pitch and should follow the same rules. Hopkins believed in using hard descriptions over hype, and text over image: “The more you tell, the more you sell” and “White space is wasted space” were his mantras. Hopkins believed that any illustrations used in an ad should be directly relevant to the product itself, not just a loose or emotional association. He insisted on avoiding “frivolity” at all costs, arguing that “no one ever bought from a clown.” Although some images did appear in advertisements and on packaging as early as the 1800s - the Quaker Oats man showed up in 1877 - these weren¹t consciously crafted to induce psychological states in customers. They were meant just to help people remember one brand over another. How better to recall the brand Quaker than to see a picture of one? It wasn’t until the 1930s, 1940s, and 1950s, as Americans turned toward movies and television and away from newspapers and radio, that advertisers’ focus shifted away from describing their brands and to creating images for them. During these decades, Midwestern adman Leo Burnett concocted what is often called the Chicago school of advertising, in which lovable characters are used to represent products. Green Giant, which was originally just the Minnesota Valley Canning Company’s code name for an experimental pea, became the Jolly Green Giant in young Burnett’s world of animated characters. He understood that the figure would make a perfect and enticing brand image for an otherwise boring product and could also serve as a mnemonic device for consumers. As he watched his character grow in popularity, Burnett discovered that the mythical figure of a green giant had resonance in many different cultures around the world. It became a kind of archetype and managed to penetrate the psyche in more ways than one. Burnett was responsible for dozens of character-based brand images, including Tony the Tiger, Charlie the Tuna, Morris the Cat, and the Marlboro Man. In each case, the character creates a sense of drama, which engages the audience in the pitch. This was Burnett’s great insight. He still wanted to sell a product based on its attributes, but he knew he had to draw in his audience using characters. Brand images were also based on places, like Hidden Valley Ranch salad dressing, or on recognizable situations, such as the significant childhood memories labelled “Kodak moments” or a mother nurturing her son on a cold day, a defining image for Campbell’s soup. In all these cases, however, the moment, location, or character went only so far as to draw the audience into the ad, after which they would be subjected to a standard pitch: ‘Soup is good food’, or ‘Sorry, Charlie, only the best tuna get to be Starkist’. Burnett saw himself as a homespun Midwesterner who was contributing to American folklore while speaking in the plain language of the people. He took pride in the fact that his ads used words like “ain’t”; not because they had some calculated psychological effect on the audience, but because they communicated in a natural, plainspoken style. As these methods found their way to Madison Avenue and came to be practiced much more self-consciously, Burnett¹s love for American values and his focus on brand attributes were left behind. Branding became much more ethereal and image-based, and ads only occasionally nodded to a product’s attributes. In the 1960s, advertising gurus like David Ogilvy came up with rules about television advertising that would have made Claude Hopkins shudder. “Food in motion” dictated that food should always be shot by a moving camera. “Open with fire” meant that ads should start in a very exciting and captivating way. Ogilvy told his creatives to use supers - text superimposed on the screen to emphasize important phrases and taglines. All these techniques were devised to promote brand image, not the product. Ogilvy didn’t believe consumers could distinguish between products were it not for their images. In Ogilvy on Advertising, he explains that most people cannot tell the difference between their own “favourite” whiskey and the closest two competitors’: ‘Have they tried all three and compared the taste? Don¹t make me laugh. The reality is that these three brands have different images which appeal to different kinds of people. It isn¹t the whiskey they choose, it’s the image. The brand image is ninety percent of what the distiller has to sell.’ (Ogilvy, 1993). Thus, we learned to “trust our car to the man who wears the star” not because Texaco had better gasoline than Shell, but because the company’s advertisers had created a better brand image. While Burnett and his disciples were building brand myths, another school of advertisers was busy learning about its audience. Back in the 1920s, Raymond Rubicam, who eventually founded the agency Young and Rubicam, thought it might be interesting to hire a pollster named Dr. Gallup from Northwestern University to see what could be gleaned about consumers from a little market research. The advertising industry’s version of cultural anthropology, or demographics, was born. Like the public-relations experts who study their target populations in order to manipulate them later, marketers began conducting polls, market surveys, and focus groups on the segments of the population they hoped to influence. And to draw clear, clean lines between demographic groups, researchers must almost always base distinctions on four factors: race, age, sex, and wages. Demographic research is reductionist by design. I once consulted to an FM radio station whose station manager wanted to know, “Who is our listener?” Asking such a question reduces an entire listenership down to one fictional person. It’s possible that no single individual will ever match the “customer profile” meant to apply to all customers, which is why so much targeted marketing often borders on classist, racist, and sexist pandering. Billboards for most menthol cigarettes, for example, picture African-Americans because, according to demographic research, black people prefer them to regular cigarettes. Microsoft chose Rolling Stones songs to launch Windows 95, a product targeted at wealthy baby boomers. “The Women’s Global Challenge” was an advertising-industry-created Olympics for women, with no purpose other than to market to active females. By the 1970s, the two strands of advertising theory - demographic research and brand image - were combined to develop campaigns that work on both levels. To this day, we know to associate Volvos with safety, Dr. Pepper with individuality, and Harley-Davidson with American heritage. Each of these brand images is crafted to appeal to the target consumer’s underlying psychological needs: Volvo ads are aimed at upper-middle-class white parents who fear for their children’s health and security, Dr. Pepper is directed to young nonconformists, and the Harley-Davidson image supports its riders’ self-perception as renegades. Today’s modern (or perhaps postmodern) brands don’t invent a corporate image on their own; they appropriate one from the media itself, such as MetLife did with Snoopy, Butterfinger did with Bart Simpson, or Kmart did by hiring Penny Marshall and Rosie O’Donnell. These mascots were selected because their perceived characteristics match the values of their target consumers - not the products themselves. In the language of today’s marketers, brand images do not reflect on products but on advertisers’ perceptions of their audiences’ psychology. This focus on audience composition and values has become the standard operating procedure in all of broadcasting. When Fox TV executives learned that their animated series “King of the Hill”, about a Texan propane distributor, was not faring well with certain demographics, for example, they took a targeted approach to their character’s rehabilitation. The Brandweek piece on Fox’s ethnic campaign uncomfortably dances around the issue. Hank Hill is the proverbial everyman, and Fox wants viewers to get comfortable with him; especially viewers in New York, where “King of the Hill”’s homespun humor hasn’t quite caught on with the young urbanites. So far this season, the show has pulled in a 10.1 rating/15 share in households nationally, while garnering a 7.9 rating/12 share in New York (Brandweek, 1997) As far as Fox was concerned, while regular people could identify with the network’s new “everyman” character, New Yorkers weren’t buying his middle-American patter. The television show’s ratings proved what TV executives had known all along: that New York City’s Jewish demographic doesn’t see itself as part of the rest of America. Fox’s strategy for “humanizing” the character to those irascible urbanites was to target the group’s ethnographic self-image. Fox put ads for the show on the panels of sidewalk coffee wagons throughout Manhattan, with the tagline “Have a bagel with Hank”. In an appeal to the target market’s well-developed (and well-researched) cynicism, Hank himself is shown saying, “May I suggest you have that with a schmear”. The disarmingly ethnic humor here is meant to underscore the absurdity of a Texas propane salesman using a Jewish insider’s word like “schmear.” In another Upper West Side billboard, Hank’s son appeals to the passing traffic: “Hey yo! Somebody toss me up a knish!” As far as the New York demographic is concerned, these jokes transform the characters from potentially threatening Southern rednecks into loveable hicks bending over backward to appeal to Jewish sensibilities, and doing so with a comic and, most important, nonthreatening inadequacy. Today, the most intensely targeted demographic is the baby - the future consumer. Before an average American child is twenty months old, he can recognize the McDonald’s logo and many other branded icons. Nearly everything a toddler encounters - from Band-Aids to underpants - features the trademarked characters of Disney or other marketing empires. Although this target market may not be in a position to exercise its preferences for many years, it pays for marketers to imprint their brands early. General Motors bought a two-page ad in Sports Illustrated for Kids for its Chevy Venture minivan. Their brand manager rationalized that the eight-to-fourteen-year-old demographic consists of “back-seat consumers” (Leonhardt, 1997). The real intention of target marketing to children and babies, however, goes deeper. The fresh neurons of young brains are valuable mental real estate to admen. By seeding their products and images early, the marketers can do more than just develop brand recognition; they can literally cultivate a demographic’s sensibilities as they are formed. A nine-year-old child who can recognize the Budweiser frogs and recite their slogan (Bud-weis-er) is more likely to start drinking beer than one who can remember only Tony the Tiger yelling, “They¹re great!” (Currently, more children recognize the frogs than Tony.) This indicates a long-term coercive strategy. The abstraction of brand images from the products they represent, combined with an increasing assault on our demographically targeted psychological profiles, led to some justifiable consumer paranoia by the 1970s. Advertising was working on us in ways we couldn’t fully understand, and people began to look for an explanation. In 1973, Wilson Bryan Key, a communications researcher, wrote the first of four books about “subliminal advertising,” in which he accused advertisers of hiding sexual imagery in ice cubes, and psychoactive words like “sex” onto the airbrushed surfaces of fashion photographs. Having worked on many advertising campaigns from start to finish, in close proximity to everyone from copywriters and art directors to printers, I can comfortably put to rest any rumours that major advertising agencies are engaging in subliminal campaigns. How do images that could be interpreted as “sexual” show up in ice cubes or elbows? The final photographs chosen for ads are selected by committee out of hundreds that are actually shot. After hours or days of consideration, the group eventually feels drawn to one or two photos out of the batch. Not surprising, these photos tend to have more evocative compositions and details, but no penises, breasts, or skulls are ever superimposed onto the images. In fact, the man who claims to have developed subliminal persuasion, James Vicary, admitted to Advertising Age in 1984 that he had fabricated his evidence that the technique worked in order to drum up business for his failing research company. But this confession has not assuaged Key and others who relentlessly, perhaps obsessively, continue to pursue those they feel are planting secret visual messages in advertisements. To be fair to Key, advertisers have left themselves open to suspicion by relegating their work to the abstract world of the image and then targeting consumer psychology so deliberately. According to research by the Roper Organization in 1992, fifty-seven percent of American consumers still believe that subliminal advertising is practiced on a regular basis, and only one in twelve think it “almost never” happens. To protect themselves from the techniques they believe are being used against them, the advertising audience has adopted a stance of cynical suspicion. To combat our increasing awareness and suspicion of demographic targeting, marketers have developed a more camouflaged form of categorization based on psychological profiles instead of race and age. Jim Schroer, the executive director of new marketing strategy at Ford explains his abandonment of broad-demographic targeting: ‘It’s smarter to think about emotions and attitudes, which all go under the term: psychographics - those things that can transcend demographic groups.’ (Schroer, 1997) Instead, he now appeals to what he calls “consumers’ images of themselves.” Unlike broad demographics, the psychographic is developed using more narrowly structured qualitative-analysis techniques, like focus groups, in-depth interviews, and even home surveillance. Marketing analysts observe the behaviors of volunteer subjects, ask questions, and try to draw causal links between feelings, self-image, and purchases. A company called Strategic Directions Group provides just such analysis of the human psyche. In their study of the car-buying habits of the forty-plus baby boomers and their elders, they sought to define the main psychological predilections that human beings in this age group have regarding car purchases. Although they began with a demographic subset of the overall population, their analysis led them to segment the group into psychographic types. For example, members of one psychographic segment, called the ³Reliables,² think of driving as a way to get from point A to point B. The “Everyday People” campaign for Toyota is aimed at this group and features people depending on their reliable and efficient little Toyotas. A convertible Saab, on the other hand, appeals to the ³Stylish Fun² category, who like trendy and fun-to-drive imports. One of the company’s commercials shows a woman at a boring party fantasizing herself into an oil painting, where she drives along the canvas in a sporty yellow Saab. Psychographic targeting is more effective than demographic targeting because it reaches for an individual customer more directly - like a fly fisherman who sets bait and jiggles his rod in a prescribed pattern for a particular kind of fish. It’s as if a marketing campaign has singled you out and recognizes your core values and aspirations, without having lumped you into a racial or economic stereotype. It amounts to a game of cat-and-mouse between advertisers and their target psychographic groups. The more effort we expend to escape categorization, the more ruthlessly the marketers pursue us. In some cases, in fact, our psychographic profiles are based more on the extent to which we try to avoid marketers than on our fundamental goals or values. The so-called “Generation X” adopted the anti-chic aesthetic of thrift-store grunge in an effort to find a style that could not be so easily identified and exploited. Grunge was so self-consciously lowbrow and nonaspirational that it seemed, at first, impervious to the hype and glamour normally applied swiftly to any emerging trend. But sure enough, grunge anthems found their way onto the soundtracks of television commercials, and Dodge Neons were hawked by kids in flannel shirts saying “Whatever.” The members of Generation X are putting up a good fight. Having already developed an awareness of how marketers attempt to target their hearts and wallets, they use their insight into programming to resist these attacks. Unlike the adult marketers pursuing them, young people have grown up immersed in the language of advertising and public relations. They speak it like natives. As a result, they are more than aware when a commercial or billboard is targeting them. In conscious defiance of demographic-based pandering, they adopt a stance of self-protective irony‹distancing themselves from the emotional ploys of the advertisers. Lorraine Ketch, the director of planning in charge of Levi¹s trendy Silvertab line, explained, “This audience hates marketing that’s in your face. It eyeballs it a mile away, chews it up and spits it out” (On Advertising, 1998). Chiat/Day, one of the world’s best-known and experimental advertising agencies, found the answer to the crisis was simply to break up the Gen-X demographic into separate “tribes” or subdemographics - and include subtle visual references to each one of them in the ads they produce for the brand. According to Levi’s director of consumer marketing, the campaign meant to communicate, “We really understand them, but we are not trying too hard” (On Advertising, 1998). Probably unintentionally, Ms. Ketch has revealed the new, even more highly abstract plane on which advertising is now being communicated. Instead of creating and marketing a brand image, advertisers are creating marketing campaigns about the advertising itself. Silvertab’s target market is supposed to feel good about being understood, but even better about understanding the way they are being marketed to. The “drama” invented by Leo Burnett and refined by David Ogilvy and others has become a play within a play. The scene itself has shifted. The dramatic action no longer occurs between the audience and the product, the brand, or the brand image, but between the audience and the brand marketers. As audiences gain even more control over the media in which these interactive stories unfold, advertising evolves ever closer to a theatre of the absurd. excerpted from Coercion: Why We Listen to What "They" Say)? Works Cited Ogilvy, David. Ogilvy on Advertising. New York: Vintage, 1983. Brandweek Staff, "Number Crunching, Hollywood Style," Brandweek. October 6, 1997. Leonhardt, David, and Kathleen Kerwin, "Hey Kid, Buy This!" Business Week. June 30, 1997 Schroer, Jim. Quoted in "Why We Kick Tires," by Carol Morgan and Doron Levy. Brandweek. Sept 29, 1997. "On Advertising," The New York Times. August 14, 1998 Citation reference for this article Substitute your date of access for Dn Month Year etc... MLA Style Rushkoff, Douglas. "Coercion " M/C: A Journal of Media and Culture< http://www.media-culture.org.au/0306/06-coercion.php>. APA Style Rushkoff, D. (2003, Jun 19). Coercion . M/C: A Journal of Media and Culture, 6,< http://www.media-culture.org.au/0306/06-coercion.php>