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Step 1 to end military suicides

This week is National Suicide Prevention Week, and we’ve invited John Bateson to write a series of articles on one group that is particularly vulnerable: military service members. The first part of the five part series follows.

Fifteen years ago, the suicide rate among patients in a large behavioral care system in Detroit was seven times the national average. Then leaders there decided to tackle the problem. The first question asked was what should be the goal—to cut the rate in half, reduce it to the national level, or more? One employee said even a single suicide was unacceptable if it was your loved one, and that helped set the target: zero.

It might seem unrealistic, but the behavioral health services division of the Henry Ford Health System proceeded anyway. Dr. C. Edward Coffey, who headed the effort, found that rather than being daunted, employees were energized by the goal, so much so that pursuing perfection became an integral part of the system’s clinical care. Coffey notes today that if 99.9% accuracy is good enough, then 12 babies in this country will be given to the wrong parents every day, 18,000 pieces of US mail will be mishandled every hour, and two million tax records will be lost every year by the IRS.

In four years, suicides at Henry Ford were reduced by 75 percent. This was good, but not good enough. With more work, the rate went down to zero and stayed there, at last count, for two-and-a-half years. How?

Every time a patient sought care, regardless of the reason, he or she was assessed for suicide risk, with specific interventions crafted for each of three risk levels.
Every employee who came in contact with patients had to take a course in suicide prevention and score 100 percent on a test—perfection—or retake it.
Policies were implemented to provide timely care by enabling patients to get immediate help through email consultations with physicians and same-day medical appointments. Patients could get prescriptions filled the same day they were called in, too.
Protocols were developed to remove weapons from the homes of suicidal patients.

The time has come for officials to demonstrate a genuine commitment to end military suicides. Not just reduce them, but end them.

It was a huge commitment, but showed what was possible. A similar commitment by the military could achieve dramatic results, at least among active-duty troops. These troops are in the system now, their activities are monitored every day, so there are numerous opportunities for assessment and treatment.

If the military followed the Detroit model, all troops would be evaluated for post-traumatic stress and suicide risk when they returned home, not just those who asked for help. Evaluations would be in person and one-on-one, not done in a group with written questionnaires, as has been the practice in the past. In addition, evaluations would be conducted multiple times up to three years following deployment to allow for delayed reactions. Family members would be interviewed as well, separately and confidentially.

Despite throwing millions of dollars at the problem—far more than is spent to prevent civilian suicides—the military continues to experience a staggering number of deaths. Every day an active-duty service member dies by his or her hand, and every hour a veteran does the same. The time has come for officials to demonstrate a genuine commitment to end military suicides. Not just reduce them, but end them. Following Henry Ford’s lead in Detroit would be a good start.

Featured image: Departure Ceremony by The US Army. CC BY 2.0 via Flickr.

The post Step 1 to end military suicides appeared first on OUPblog.

Step 1 to end military suicide

This week is National Suicide Prevention Week, and we’ve invited John Bateson to write a series of articles on one group that is particularly vulnerable: military service members. The first part of the five part series follows.

Fifteen years ago, the suicide rate among patients in a large behavioral care system in Detroit was seven times the national average. Then leaders there decided to tackle the problem. The first question asked was what should be the goal—to cut the rate in half, reduce it to the national level, or more? One employee said even a single suicide was unacceptable if it was your loved one, and that helped set the target: zero.

It might seem unrealistic, but the behavioral health services division of the Henry Ford Health System proceeded anyway. Dr. C. Edward Coffey, who headed the effort, found that rather than being daunted, employees were energized by the goal, so much so that pursuing perfection became an integral part of the system’s clinical care. Coffey notes today that if 99.9% accuracy is good enough, then 12 babies in this country will be given to the wrong parents every day, 18,000 pieces of US mail will be mishandled every hour, and two million tax records will be lost every year by the IRS.

In four years, suicides at Henry Ford were reduced by 75 percent. This was good, but not good enough. With more work, the rate went down to zero and stayed there, at last count, for two-and-a-half years. How?

Every time a patient sought care, regardless of the reason, he or she was assessed for suicide risk, with specific interventions crafted for each of three risk levels.
Every employee who came in contact with patients had to take a course in suicide prevention and score 100 percent on a test—perfection—or retake it.
Policies were implemented to provide timely care by enabling patients to get immediate help through email consultations with physicians and same-day medical appointments. Patients could get prescriptions filled the same day they were called in, too.
Protocols were developed to remove weapons from the homes of suicidal patients.

The time has come for officials to demonstrate a genuine commitment to end military suicides. Not just reduce them, but end them.

It was a huge commitment, but showed what was possible. A similar commitment by the military could achieve dramatic results, at least among active-duty troops. These troops are in the system now, their activities are monitored every day, so there are numerous opportunities for assessment and treatment.

If the military followed the Detroit model, all troops would be evaluated for post-traumatic stress and suicide risk when they returned home, not just those who asked for help. Evaluations would be in person and one-on-one, not done in a group with written questionnaires, as has been the practice in the past. In addition, evaluations would be conducted multiple times up to three years following deployment to allow for delayed reactions. Family members would be interviewed as well, separately and confidentially.

Despite throwing millions of dollars at the problem—far more than is spent to prevent civilian suicides—the military continues to experience a staggering number of deaths. Every day an active-duty service member dies by his or her hand, and every hour a veteran does the same. The time has come for officials to demonstrate a genuine commitment to end military suicides. Not just reduce them, but end them. Following Henry Ford’s lead in Detroit would be a good start.

Featured image: Departure Ceremony by The US Army. CC BY 2.0 via Flickr.

The post Step 1 to end military suicide appeared first on OUPblog.

‘Us’ and ‘Them': Can we define national identity?

Surveys show that a high percentage of British citizens “feel British.” But what exactly do people have in mind when they say this? People may think differently about this question, and perhaps it is also British to give various meanings to British identity. Still, can we define what it is to “feel” British? Or even what is un-British—be it a pattern of behavior, a belief, or a way of doing things?

In 2002, the Home Office published a report on the essence of Britishness: “To be British seems to us to mean that we respect the laws, the elected parliamentary and democratic political structures, traditional values of mutual tolerance, respect for equal rights and mutual concern… to be British is to respect those over-arching specific institutions, values, beliefs and traditions that bind us all.” Three years later, in 2005, the Commission for Racial Equality offered its own version of what is uniquely Britishness. Britain, it found, is a constitutional monarchy, a parliamentary system, a white English-speaking country, and a democracy that cherishes freedom, the rule of law, fairness, and tolerance.

ETHNOS Research and Consultancy by the Commission for Racial Equality (CRE) in 2005
Immigration Policy and National Identity

Until not so long ago, European countries did not struggle with the question “who are we,” or search for a bond to bind them together. National identity was a given, not something that had to be defined. But times have changed. The question of immigration, together with globalization processes and the rise of minority rights and multiculturalism, have led to a new reality where it becomes more difficult to know what it means to have a national identity, how legitimate it is to act upon such identities or impose them on newcomers. Immigration, more than anything else, has brought to the fore the question of national identity, encouraging nation-states to define themselves. As George Orwell rightly observed, “It is only when you meet someone of a different culture from yourself that you begin to realize what your own beliefs really are.”

National identities have traditionally not been legal concepts. Perhaps for the first time in human history, states currently offer, or attempt to offer, a legal definition of their collective identity. Immigration law is the field in which this fascinating phenomenon is taking place.

Search for an Identity

Stormy Sky Above Mont Saint-Michel. Photo by A Guy Taking Pictures. CC BY 2.0 via Flickr.

Nation-states all over the world are seeking to construct a unique national character to be shared and celebrated, and to find a distinguishing identity.

Take France, for example. In November 2009, President Sarkozy launched a nationwide discussion over the meaning of being French. “For you, what does it mean to be French?” he asked the public. The three-month public debate sparked a heated discussion, both over the wisdom of such a debate and over the essence of being French. Whether the campaign was a political ploy or a real exercise in nation-building, the attempt to summarize the essence of Frenchness was an interesting move. It shows that when nation-states start to examine what holds a people together, they quite often conclude that there are more sources of division than unity.

Questioning the qualities one should possess to become French is not just a philosophical, but also legal issue. The Conseil d’Etat, the highest French administrative court, has ruled that it is justified to deny citizenship if a candidate acts in a way that is incompatible with the “values essential to the French communauté.” The Court, however, did not offer guiding standards of what one should do, or avoid doing, in order to assimilate into the French way of life, nor did it provide a definition of “values essential to the French communauté.” Surely, if living together in France means knowing and respecting French values, it is better to know what they are.

Citizenship Tests

Immigration law provides a unique platform to reflect on three issues: defining the “we,” setting criteria for identifying the desired “they,” and finding the core to which “they” should subscribe to become part of “us.” Naturalization requirements—the criteria that “they” must fulfill in order to join “us”—define “our” way of living, form of thinking, and mode of behavior. Citizenship tests, in particular, are an interesting way to learn about a society’s collective identities, aspirations, and hopes. They can help clarify who is, in the state’s view, a “good citizen,” and the current understanding of what it means to become a citizen in a liberal state.

In less than a decade, Britain has changed its concept of Britishness, as reflected in the test, three times!

Take Britain, for instance. Starting in 2005, every person asking to settle in the United Kingdom must demonstrate “sufficient knowledge about life in the United Kingdom” by passing the Life in the UK Test. In less than a decade, Britain has changed its concept of Britishness, as reflected in the test, three times! The first edition (2005) and the second edition (2007) of the official handbook of the Life in the UK Test did not focus on British history, and downgraded British identity to daily life issues. A person had to know what people do on Valentine’s Day (lovers exchange gifts and cards), what is the Grand National (an annual steeplechase), and how might you stop young people playing tricks on you on Halloween (give them sweets). For example, the applicant had to know how to buy a ticket for the Underground and that dogs in public places must wear a collar that shows the name and address of the owner.

In March 2013, Britain revised its national identity, as reflected in the Life in the UK Test and, for the first time, incorporated British history. To become British, one has to be familiar with Chaucer, Shakespeare, Lord Byron, Charles Dickens, Adam Smith, Isaac Newton, the Beatles, and British soap operas. The applicant has to find their way in a royal maze: John, Henry V, Henry VII, Elizabeth I, Charles I, and Henry VIII, not to mention a long list of Henry VIII’s wives – (and he had six!). The new handbook is like a renaissance of British identity. One of the most detailed parts of the handbook relates to sports. It contains a long list of notable British sportsmen and detailed explanations on cricket, rugby, and football. Even issues such as shopping, cooking, and gardening have become uniquely British. (“The countries that make up the UK all have flowers which are particularly associated with them.”) The British also have a unique cuisine, theater, and comedy. They are also cool and modern. They use Facebook and Twitter and go out to pubs and night-clubs, and like to gamble, especially on sports.

Collective Identity

Westminster Bridge. Photo by Leonard Bentley. CC BY-SA 2.0 via Flickr

In drafting a citizenship test, we tell a story about ourselves and our country. What are the elements of a national story? Three elements exist. The first part of a story includes facts, attributes of who “we” actually are. The second part of the story includes “imagined” facts, attributes that “we” ideally hope to possess. This part includes romantic conceptions of ourselves, representing a romantic ideal of ‘the good old days’. This is a blend of fiction and non-fiction of the contemporary “we.” The third part of the story includes “ought-to-be facts,” attributes that are not the best description of the “we” but, rather, the attributes that “we” want other people to think that “we” possess. This part includes those details aimed at deterring certain people and encouraging others.

Think of online dating sites as an analogy. Persons who subscribe to the service go through a process of defining their “self.” A person should specify physical information (hair color, height, weight), personal details (education, occupation, date of birth), and lifestyle (smoking, drinking, willingness to relocate). While these details are factual, similar to details about demography or geography, other details are more complex: “my life ambitions are…”, “my personality is best described as…”, “the things I could never live without are…”, “for fun, I like to…”. Studies show that persons who subscribe to online dating websites define their identity by referring to three aspects of their self. The first is the actual self. People write factual details about their weight and height. The second is the ideal self. People write details that they believe to be factual. A person can describe his “body style” as muscular and athletic, even though his real body is plump and flabby. A person may choose a wrong description of his self not because he lies, but because he indeed believes that he has an athletic body style; this is an imagined “self.” The third is the ought-to-be self. People write details that are fiction since they want others to believe that they possess certain attributes. For instance, a woman may say that she likes classical music, even though she really likes techno music, because she believes that classical music will further impress her targeted audience.

Liberal states don’t ask immigrants to be “like us,” but better than us. Citizenship tests don’t focus on what British actually are, but on what they think they are (the ideal self). By means of immigration laws, states develop an imagined story of a culturally homogenous group that speaks the same language, shares the same values, and celebrates the same holidays—as if all people are the same. They offer a fictional description of who they are by romanticizing who they were or want to be. Then, they ask to impose part of this prescription on immigrants in order to promote cohesion and unity.

National Identity and Global Migration

What can immigration policy teach us about national identity? On one hand, some National identity debates end up with seemingly trivial issues, items of popular culture like movies, carnivals, and sports. This “Disneyfication of cultural difference,” as termed by Will Kymlicka, may be the greatest indicator of a national identity crisis. Political leaders in the West declare the death of multiculturalism and seek to focus on “our” culture, yet cannot pinpoint exactly what this culture is. In a sense, they find out that the shared culture is, at best, a particular version of political liberalism.

On the other hand, some national identity debates end up with “high culture”—Rembrandt, Molière, Nietzsche, or Shakespeare. As a large percentage of the public is not well-versed in this information, this looks like an attempt to romanticize collective identity. It may be more what we think we are (ideal self), or want other people to think we are (ought-to-be self), than who we are (actual self).

Talking about the national identities in an age of globalization may seem a bit old fashioned. Trans-cultural diffusion is greater today than in any other period in human history. In the contemporary world, ideas come and go— through free markets, international media, and the Internet—and the notion of cultural exceptionalism faces multiple challenges. The “other” is present in national boundaries not just physically but spiritually. Cultures change, and they will continue to change more rapidly than ever. Even if states can control the flow of people, they can hardly control the flow of cultures. It is too early to predict whether we are witnessing the “swan song” of the old structure of national identity, or its transformation.

Featured image: Hackney Weekend queue. Photo by Steve Bowbrick. CC BY 2.0 via bowbrick Flickr.

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A fairy tale is more than just a fairy tale

When some one says to you – and I’ve heard this comment in English, French, German, Spanish, and Italian – “that’s just a fairy tale,” it generally means that what you have just said is untrue or unreal. It is a polite but deprecating way of saying that your words form a lie or gossip. Your story is make-believe and unreliable. It has nothing to do with reality and experience. Fairy tale is thus turned into some kind of trivial story – silly, infantile, not to be believed. Moreover, fairy tales are allegedly for children, amusing stories to pass the time away and to be dismissed. If children believe in them, read them and listen to them, they cannot be taken seriously.

Yet, we all know that the opposite is true. We all know we believe or want to believe in fairy tales. We are all ready to answer Peter Pan’s monumental question whether we believe in fairy tales with a resounding “yes!” We all know that fairy tales are tied to real life experiences more than we pretend they aren’t. We ward off fairy tales and pretend that they are intended mainly for children because they tell more truth than we want to know, and we absorb fairy tales because they tell us more truth than we want to know. They are filled with desire and optimism. They drip with brutality, bluntness, violence, and perversity. They expose untruth, and the best are bare, brusque, and concise. They stamp our minds and perhaps our souls. They form another world, a counter world, in which social justice is more readily attained than in our actual world where hypocrisy, corruption, hyping, exploitation, and competition determine the outcome of social and political interactions and the quality of social relations.

“Russische sprookjes poster,” by marlarle. CC BY-SA 2.0 via Flickr.

Though it is impossible to trace the historical origins and evolution of fairy tales to a particular time and place, we do know that humans began telling tales as soon as they developed the capacity of speech. They may have even used sign language before speech originated to communicate vital information for adapting to their environment. Units of this information gradually formed the basis of narratives that enabled humans to learn about themselves and the worlds that they inhabited. Informative tales were not given titles. They were simply told to mark an occasion, to set an example, to warn about danger, to procure food, to explain what seemed inexplicable. People told stories to communicate knowledge and experience in social contexts. Though many ancient tales might seem to us to be magical, miraculous, fanciful, superstitious, or unreal, people believed them, and they were and are not much different from people today who believe in religions, miracles, cults, nations, and notions such as “free” democracies that have little basis in reality. In fact, religious and patriotic stories have more in common with fairy tales than we realize except that fairy tales tend to be secular and are not based on a prescriptive belief system or religious codes. Fairy tales are informed by a human disposition to action – to transform the world and make it more adaptable to human needs while we try to change and make ourselves fit for the world. Therefore, the focus of fairy tales, whether oral, written, or cinematic, has always been on finding magical instruments, extraordinary technologies, or powerful people and animals that will enable protagonists to transform themselves and their environment and make it more suitable for living in peace and contentment. Fairy tales begin with conflict because we all begin our lives with conflict. We are all misfit for the world, and somehow we must fit in, fit in with other people, and thus we must invent or find the means through communication to satisfy and resolve conflicting desires and instincts.

Fairy tales are rooted in oral traditions, and they were never given titles, nor did they exist in the forms in which they are told, printed, painted, recorded, performed, and filmed today. They were never specifically intended for children. Folklorists generally make a distinction between wonder folk tales, which originated in oral traditions throughout the world and still exist, and literary fairy tales, which emanated from the oral traditions through the mediation of manuscripts and print and continue to be created today in various mediated forms throughout the world. In both the oral and literary traditions the tale types influenced by cultural patterns are so numerous and diverse that it is almost impossible to define a wonder folk tale or a fairy tale or explain the relationship between the two modes of communication. In fact, together, oral and literary tales form one immense and complex genre because they are inextricably dependent on one another.

One thing is clear: this genre that we call a fairy tale is utterly relevant in its vast and diverse forms, glimmers with truth, and keeps challenging us to definite it.

Featured image credit: Classics for Summer Reading, by David Masters. CC BY-SA 2.0 via Flickr. 

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Where is architecture truly ‘modern’?

Too often, we in Europe and the English-speaking world presume that we have a monopoly on both modernity and its cultural expression as modernism. But this has never been the case. Take, for instance, the case of sixteenth and seventeenth century urbanism in Europe and Asia. One can focus on the different ways in which classical precedent was deployed in Europe, teasing out the distinctions between the early and late Renaissance, not to mention Mannerism and Baroque. These had no exact counterparts in the Ottoman, Safavid, and Mughal empires, which stretched east from Budapest to what is now Bangladesh. Indeed, even many northern Europeans were slow to be impressed, although the revival of antique classicism certainly left its imprint upon Iberian colonial outposts (One can find sixteenth and seventeenth century churches with Roman-inspired facades in the Yucatan, Macau, and more). But from Madrid to Delhi, many capitals nonetheless shared the same new features during these years. The emergence of large, logically organized public spaces lined by uniform facades, broad tree-lined boulevards, and domed houses of worship tied these places together and evoked paradigms that been established even earlier to the east, especially in Beijing. The court cultures of Istanbul, Isfahan, and Delhi made almost exactly the same breaks with their medieval pasts as their counterparts in Paris, Madrid, and Rome.

And yet real differences do endure. Over the course of the last century, what is striking is not that cities and buildings around the world have become more similar, but that the Latin American, Asian, and even African urban middle class have typically been far more receptive than Europeans to 1920s avant-garde architects who broke away from historical tradition. Liberation from the past is also uncommon in the English-speaking world, where timber, brick, and other references to the pre-industrial rural vernacular characterize most suburban housing; living rooms and parlors, if not kitchens and bathrooms, often contain replicas of furniture first produced more than two centuries ago. But this is much less likely to be the case if one is an accountant, engineer, surgical nurse, or elementary school teacher in Shanghai or Santiago. Here, home is also more likely to be a multi-story tower, an option still associated—in much of Europe and the English-speaking world—with warehousing the poor or the luxurious aeries of the super-rich.

“Plaza Mayor (square) in Madrid (Spain) at dusk” by Sebastian Dubiel. CC BY-SA 3.0 DE via Wikimedia Commons

Architecture does not necessarily reflect reality. It is more likely to give concrete form to the fantasies of those with the agency to shape their environments, a group that has always included consumers as much as architects. The Safavid and the Spanish courts shared a focus on court spectacle in support of the highly centralized rule that, like prosperity rooted in intercontinental trade, proved difficult to sustain. Public spaces like the Maidan and the Plaza Mayor were intended to facilitate both, despite being wrapped in architectural languages that spoke to distinct inheritances, that of pre-Islamic Iran in Isfahan, and the Roman empire in Madrid. When both were new, Isfahan may have looked—and indeed may have been—as modern as Madrid, but political and economic development would first be achieved by Amsterdam and then London. Here, prosperity, rather than being mapped out by monarchs, bubbled up from the compelling collective endeavor of the middle class, despite less spatial coherence. Similarly, the splendor of Baroque Rome far exceeded anything erected by Popes who still controlled all of western Christendom.

Today, few searching for a dynamic architectural present and future look to Europe or the United States, where cities are increasingly ceded to tourists rather than inhabitants. Meanwhile, modernism’s purported identity as an objective representation of an industrial future has often proved to be nothing more than a rhetorical stance, its boldest new expressions designed to glorify such spectacles such as the Olympics, whose efficacy is likely to be on par with the Counter-reformation’s success at stamping out Protestantism. While nothing about the slated gables and bay windows of Mount Merrion precludes living an entirely modern life, (children raised in both settings are more likely to end up as physicians in Australia or engineers in Canada than gentleman farmers in rural England), lived modern urbanity now lies elsewhere. The rapidly changing, impoverished, and abysmally polluted streets and skylines of Dubai, Mumbai, and Shanghai are seldom beautiful, but they are abundantly alive. They are as emblematic of our shared future as the palaces and plazas of Madrid and Isfahan are of our shared past.

Image Credit: “Naghsh-i Jahan Square, Isfahan, Iran” by Arad Mojtahedi. CC BY-SA 3.0 via Wikimedia Commons

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Scrutinizing the script of the medieval ‘Tremulous Hand of Worcester’

How would we know if a medieval person had a neurological disorder? If we did know, would it be possible to pinpoint the type of condition? What insight can we gain about the practical impact of disorders on medieval life? Fortunately, a physical record survives that provides a reliable window into the health of medieval people—or, at least, those who were able to write.

Handwriting captures the writer’s state of health: it requires fine motor control, as well as highly-developed cognitive abilities in spatial planning, spelling, and grammar. In the period before the fifteenth-century invention of the printing press, all texts had to be written out by hand. Writing could be a profession, or an act of devotion within a religious order. Contrary to popular belief, the medieval life was not universally short and brutal—some medieval scribes lived to be 70, 80, and possibly 90 years old. Thus, medieval writing offers a wealth of insight into the lives of young and old, healthy and unhealthy people.

Historians have long been fascinated by the ‘Tremulous Hand of Worcester’. His script was first described in 1878 as “von einer zitternden hand” (“by a shaking/trembling hand”), by the German scholar Julius Zupitza. This thirteenth-century scribe, whose name remains a mystery, was probably a monk at Worcester Cathedral Priory. His handwriting appears in over 20 books, providing us with rich material for our study. However, despite the interest provoked by his distinctive, shaky script, it has never before been analysed by a neurologist. With this in mind, we created an unconventional collaboration: a medieval palaeographer (a researcher of historical handwriting) working with a neurologist with a specialist interest in movement disorders, and began to scrutinize the script.

By tracing the individual contours of the letters on the page, we gleaned information about how a neurological disorder affected the scribe’s hand movements. In addition to examining his tremor-affected strokes, and the size and shape of the letters, we consider the man’s cognitive abilities and potential concurrent symptoms. Through this study, we are now able to suggest a diagnosis for the condition that caused his tremulous writing. Since medieval people wrote with quills, we may compare the medieval script with the writing of a modern-day person with the condition using a calligraphy pen.

A monk praying at an altar with Christ above. London, British Library, Additional MS 28681, folio 118v. Used with permission.

So, what can this trembling script tell us about the daily life of a medieval person with a neurological condition? Literary scholar Christine Franzen, an expert on this scribe, had already noticed a point where his tremor was alleviated, possibly by a period of rest. Did the scribe consume alcohol during his rest? The response of some tremor conditions to alcohol is well-attested—a small amount of alcohol can steady the hand. Thus, an alcoholic drink may have offered some relief for the Tremulous Hand of Worcester. This creates an especially vivid connection between past and present—we see, visually, how a person lived with, and worked with, his neurological disorder.

Scholars still know relatively little about neurological health in the medieval period. Much of the evidence has escaped the records, especially that concerning mundane daily life. There remain many puzzles to be solved, too, about the lives of scribes in the Middle Ages. By focusing on this man, we create an important historical perspective on the experience of tremor, and so widen the scope of our modern medical understanding of health.

Featured image: Medieval writing desk. Public Domain via Wikimedia Commons.

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How well do you know Shakespeare’s influences? [quiz]

Many Shakespeare fans prefer to imagine him as an untrained genius, but, in reality, Shakespeare drew inspiration from many classical sources for his own writing. His most famous plays, such as Othello, Antony and Cleopatra, and Hamlet, allude to and reference external sources that Shakespeare was already familiar with. How much do you know about the influence of other writers on, what some would call, the greatest English dramatist to date?

Featured Image: “Statue of William Shakespeare at the centre of Leicester Square Gardens, London” by Elliot Brown. CC BY 2.0 via Flickr

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A snapshot of the jihadist movement today

Fighting terrorism is one of the few foreign policy issues that unites Democrats and Republicans, though of course both are quick to point fingers at any perceived failures or lapses. Yet America’s and the world’s leaders often do not recognize that the jihadist movement today is in flux, and the threat it poses differs dramatically from the 9/11 era.

Consider Al Qaeda. US Navy SEALs killed Osama bin Laden in 2011, and in 2015 Afghan intelligence revealed that his closest ally, Taliban leader Mullah Omar, had died in 2013. Many of Al Qaeda’s key lieutenants are dead or in prison, and most of the remainder are keeping their heads down, fearing a drone strike or more special operations forces swooping in to capture or kill them. Bin Laden’s number two Ayman al-Zawahiri now heads Al Qaeda, but his communiqués are few and far between, and the core organization has not conducted a significant terrorist attack in years.

Most of Al Qaeda’s remaining relevance comes from its affiliate organizations. As they’ve taken on the Al Qaeda name, their rhetoric has embraced Al Qaeda’s anti-U.S. and anti-Western focus. The Yemen-based Al Qaeda in the Arabian Peninsula (AQAP) almost downed commercial and cargo airlines over the United States, and it trained one of the shooters who slaughtered the Charlie Hebdo cartoonists in Paris in 2015. Yet, for the most part,s these groups focus on local civil wars and expanding their regional influence. Al Qaeda’s most important franchise, Jabhat al-Nusra in Syria, even claimed it was dedicated to fighting the Syria regime only and would not turn its guns against the West.

Al Qaeda’s decline, however, is balanced by the rapid ascent of the Islamic State. The Islamic State’s defense of slavery, atrocities against its enemies, and embrace of sectarianism and millenarianism make Al Qaeda seem sane and even tame by comparison. Indeed, the group split with Al Qaeda in February 2014: the two regularly condemn the other for straying from the true path, and in Syria thousands of fighters died when they turned their guns on each other. In addition to impressive military successes in Syria and Iraq, the Islamic State has captured the imagination of much of the radical community. It now claims “provinces” as far away as Afghanistan, Libya, and Nigeria. Tens of thousands of foreigners have flocked to its banners in Iraq and Syria, including over 3,000 from the United States, Europe, and Australia.

To many Americans and Westerners, the Islamic State’s brutality makes it seem like even more of a threat than Al Qaeda. Americans, understandably shy of more intervention in the Middle East after the 2003 Iraq imbroglio, even supported President Obama’s decision to bomb Islamic State forces in Iraq and Syria and deploy military trainers as well. Indeed, most critics of the president claim he is not doing enough to fight the Islamic State and should be more aggressive.

Yet focusing on the Islamic State’s brutality can lead to neglect of the true threat it poses, as well as the lingering danger represented by the remaining Al Qaeda network. The good news is that the risk of a catastrophic attack inside the United States on the scale of 9/11 is low. The Al Qaeda core is too weak, and the network, in general, is under such pressure from the world’s security services that a multi-year operation involving operatives from around the world would be difficult for it to pull off. The Islamic State, while formidable, is focusing its energies on the Middle East, not the West. It too would have difficulty pulling off a complex operation outside its home region and for now at least it doesn’t seem to want to.

The Islamic State and Al Qaeda affiliates do pose a danger to the West, but this threat is primarily to broader interests in the Middle East. The Islamic State has brought Iraq back to a state of massive civil war, and it is threatening to destabilize Lebanon, Jordan, and Saudi Arabia. Al Qaeda’s affiliates in the Maghreb, Somalia, and Yemen are exacerbating civil wars there and spreading instability throughout the region, generating massive refugee flows. Western policymakers are confronting a region in crisis, and the jihadist movement is at the core of many of the region’s problems.

The terrorism danger to the West is largely in the form of jihadist wannabes who act on their own – so-called “lone wolves.” They may read exhortations to kill and wreak mayhem in Al Qaeda in the Arabian Peninsula’s online Inspire magazine or follow Islamic State members on Twitter, but few are working in close coordination with the main organizations abroad. These jihadists can and will pick up a gun or manufacture a crude bomb and kill innocent people. From the security services’ point of view, they are exceptionally difficult to stop: often they do not show up on the radar screen until it is too late. Yet at the same time the scope and scale of their violence is likely to be more limited. They are usually untrained and often unskilled, and they are unlikely to kill large numbers of people or strike well-defended targets.

So our politicians’ concerns about terrorism are both well founded and off base. There is indeed a threat, but it is a different one than what has dominated our public discourse in the last 15 years. Their energies would be better spent educating the public on the true dangers and building up resilience so that when lone wolves pull off small-scale attacks, the public does not panic.

Featured Image: “Explosive ordnance disposal technicians conduct demolition operations.” by Official U.S. Navy Page CC BY SA via Flickr.

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The future of aesthetic surgery

Plastic surgery, aesthetic surgery, cosmetic surgery: the field has many different names. Yet despite its high profile today, many people even within the medical field have a limited understanding of it and the drastic changes it’s undergoing. From noninvasive procedures to patient education, aesthetic surgeons face a variety of new challenges. We sat down with Foad Nahai, editor of Aesthetic Surgery Journal‎, to learn more about developments in the field.

What encouraged you to pursue a career in aesthetic surgery?

My early career was at a time when very few plastic surgeons limited their practice to aesthetic surgery. Compared to today, there was far less demand for such procedures, and media coverage of aesthetic surgery was not extensive. Like most others of that era, I focused primarily on reconstructive surgery and was fortunate to have the opportunity to contribute to the many advances that have transformed the field. As my practice and reputation as a surgeon grew, coupled with increasing interest and demand for aesthetic procedures, more and more patients sought my services for aesthetic surgery. My background in reconstructive surgery, interest in art and anatomy, and my experience as a reconstructive microsurgeon prepared me well for the transition from a heavily reconstructive practice to one that eventually became exclusively aesthetic. The ultimate encouragement came from satisfied patients who continue to refer friends and family.

What do you think are the biggest challenges being faced in the field of aesthetic surgery today?

The field of aesthetic surgery is rapidly evolving. There continue to be many new and innovative surgical advances, but the most rapid area of growth is in the arena of noninvasive procedures. Most notable is the development of a wide array of injectable products as well as new mechanical devices for noninvasive skin tightening and elimination of unwanted fat. The challenge for the practitioner is not only to keep up with these new developments but also to determine, on a scientific basis, which products and devices can best serve patients, both immediately and long term. Aesthetic Surgery Journal (ASJ) has an important role in providing the most current evidence-based information to assist our readers in evaluating these emerging technologies.

By far the major challenge to the field, however, is education of the public as to who is competent or best qualified to undertake aesthetic procedures. Given the rapid growth of aesthetic surgery, coupled with cuts in medical reimbursements and other disincentives to the practice of traditional medicine, a wide range of physicians (and even non-physicians) are enticed to enter the field of aesthetic surgery despite having little or no relevant training. Plastic surgeons have long been among those who regard “scope of practice” as a significant public safety issue and not, as some have claimed, a “turf battle.” While all surgery has some risk, no patient should subject himself or herself to the inherently greater danger when a procedure is performed by an unqualified practitioner or in a facility that fails to meet accepted safety standards.

How has the field changed in the last 25 years?

Growth, growth, and more growth! Twenty-five years ago, all that aesthetic specialists could offer patients, with the exception of skin peels, were invasive surgical procedures. This has dramatically changed. Statistics from the American Society for Aesthetic Plastic Surgery (ASAPS), published as a July 2015 Aesthetic Surgery Journal supplement, show that since 1997 the number of surgical procedures has doubled while nonsurgical procedures have increased more than tenfold. This trend will continue.

Equally influential in changing the field has been innovation in electronic communication. Although there are many positive aspects to the Internet and social media, there are also many downsides when it comes to healthcare information. Patients may often obtain the “facts” about aesthetic surgery from websites that are unreliable and lack credibility. Any assertion of an individual surgeon’s superiority can be made with virtually no challenge. In the past, being well-trained, taking good care of patients, and providing them with excellent results was all a young surgeon needed to build a successful practice. Today, physicians feel pressured to devote a good deal of time and resources in developing an online presence.

The Internet is replete with questionable, misleading, and self-serving claims. Anonymous online evaluations of physicians have largely replaced word-of-mouth recommendations. All this can make it more difficult for a surgeon to establish that all-important relationship of trust, especially with new patients. Yet adapting to these challenges, while remaining ethical and placing patient welfare above all else, is a necessary part of developing a successful practice in a fiercely competitive healthcare environment.

What do you think will change the most in the field in the future?

The changing culture of healthcare (depersonalization and lack of access to doctors) in the United States will have some effect on aesthetic surgery, though less than on many other fields since aesthetic procedures are largely elective and therefore not covered by insurance or Medicare. However, as I have alluded to earlier, more physicians without appropriate training can be expected to migrate from their own specialties into what they perceive as the more lucrative field of aesthetic surgery. This will increase competition and decrease patient safety.

Nonsurgical procedures, notably noninvasive skin tightening and fat reduction technologies, will be improved. The predictable and consistent results they achieve in the future will ultimately reduce the demand for surgical procedures. In particular, the combination of new and improved injectables and skin-tightening devices may well spell the end of surgical procedures for facial rejuvenation. In the wake of these advances, interest in and demand for nonsurgical aesthetic services will grow even more rapidly than the current pace.

What does your typical day as the Editor-in-Chief look like?

As an active aesthetic surgeon, my practice keeps me fairly busy, and the care and welfare of my patients is my top priority. After that come my many academic and professional responsibilities including Aesthetic Surgery Journal. I am up early every morning and on my computer for an hour or two, working on ASJ, before my clinical day starts at 7:30 in the operating room or 8:00 in the clinic. During the day, as my clinical schedule allows, I may tend to ASJ business, but I do most of this at the end of the day after all my clinical responsibilities have been met. As my running days are over, after two knee injuries, I exercise daily on a bicycle. Given Atlanta’s traffic and weather extremes, I “ride” a stationary bike for at least 45 minutes with iPad in hand. I read new manuscripts, assign reviewers, evaluate revised manuscripts, and make decisions on manuscripts which have completed peer review. On a typical day, including weekends, I spend two to four hours on ASJ. Beyond the peer review process, I spend time evaluating our website as well as the websites and print publications of sister journals in our own and related fields. Correspondence with authors, discussions with potential authors (many of which occur during my extensive travels to meetings and conferences around the world), and close interaction with my editorial staff also add significantly to my work hours.

How do you see the journal developing in the future?

Our plan is for Aesthetic Surgery Journal to continue to grow, both in terms of content and readership. Within the next year or so, we plan to publish ten issues per year (up from the current eight) and eventually on a monthly basis. The transition from print and online to online- only is inevitable but not imminent. Our mobile app, through RADAR, is state-of-the- art, offering innovative and unique reference and learning opportunities for our readers. Readership growth, especially internationally, will continue to accelerate as we offer enhanced accessibility options worldwide.

What do you think readers will take away from the journal?

My goal has been to build a scholarly journal serving the practicing aesthetic surgeon and the academic researcher. I am proud that Aesthetic Surgery Journal has, in a relatively short time, achieved an excellent impact factor, making this journal one in which academically-affiliated physicians and scientists choose to publish their clinically-significant research. Equally important are papers of immediate practical value to the practicing aesthetic surgeon, and we have made a concerted effort to elevate the quality of these practice-oriented manuscripts so that they reflect the evidence-based model to which we aspire. Aesthetic surgeons need both types of information: first, tried-and-true practices which they can immediately adopt and, second but no less important, research which in the longer term may impact the safety and efficacy of patient care.

What would you like to leave as your legacy to ASJ?

I have been fortunate to be surrounded by a talented and dedicated editorial board, editorial staff and to enjoy the support of the board and staff of the Journal’s sponsoring organization, the American Society for Aesthetic Plastic Surgery (ASAPS). Any legacy I leave behind is also theirs and was made possible through their efforts. Aesthetic Surgery Journal has the highest impact factor and largest circulation in its class of journals dedicated solely to aesthetic surgery. As a leading international journal, ASJ is increasingly becoming the “go to” journal for clinicians and researchers alike. I hope to build on our current success, with continued support from our readers, authors, ASAPS and the advertisers who help make all of this possible.

Featured Image Credit: Medical appointment. CC0 via Pixabay.

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Sexual decision-making for older adults with dementia

Who decides with whom we are allowed to have sex? Generally, consenting adults are considered to have the ability to make decisions regarding sexual activity and are allowed to pursue a sexual relationship with whomever they choose, assuming appropriate criteria for consent are met. Indeed, consent is crucial in any decision regarding sexual activity because, by definition, sexual abuse occurs when sexual activity is non-consensual. It is assumed, though, that we have the freedom to do what we please with our bodies and to enjoy reasonable protection against harm in all matters of our life, ranging from what happens in our bedroom (i.e. sexual decisions) to what happens in the hospital (i.e. decisions regarding acceptance or withdrawal of medical treatments).

Decisions, however, aren’t made in a vacuum. The context in which a decision is made is important in determining both the options and the stakeholders in the decision-making process. For example, older adults who reside in nursing homes have to abide by applicable policies and practices of the nursing home when making decisions. For residents with dementia who may have impaired decision-making, the nursing home often takes a more active role in decision-making, arbitrating between two potentially competing interests: providing opportunities for residents to freely and privately associate and protecting residents from harm.

Sexual expression can be an important part of quality of life for older adults. Despite myths to the contrary, there is no age at which sexuality suddenly disappears. Further, a diagnosis of dementia for an older adult does not automatically indicate an end of sexual interest. In fact, sexual intimacy may be an important avenue to combat loneliness and fear as dementia progresses. In the nursing home, however, the sexual expression of a resident with dementia can be complicated, particularly because it can be difficult to assess if an individual with dementia has the ability to consent to sexual activity.

The challenge of decision-making in such situations was recently highlighted in the case of Donna Lou Rayhons. According to an article in The New York Times, Mrs. Rayhons had dementia and was living in a nursing home while her husband lived in the community, visiting her frequently. There was concern from a daughter of Mrs. Rayhons from a previous marriage that there was inappropriate sexual contact between the married couple. A doctor in the nursing home reportedly evaluated Mrs. Rayhons and felt that she did not have the ability to consent to any sexual activity, a determination that was communicated with Mr. Rayhons. Despite this recommendation, Mr. Rayhons reportedly had sexual relations with his wife, which led to charges against him of felonious sexual abuse.

Older woman. CC0 via Pixabay.

The concern here is that if an individual with dementia is unable to demonstrate an ability to consent, there is an increased risk for sexual abuse. In medical situations, clinicians are frequently asked to assess whether an individual has the ability to make certain decisions such as whether to have an operation or to leave the hospital against medical advice. These determinations are typically made with formal assessments of capacity in which a clinician examines an individual’s ability to demonstrate a choice, understand pertinent information, reason about the various options, and appreciate the consequences of the decision.

In nursing homes, such formal capacity assessments are usually undertaken when there is concern about impairment in a resident’s decision-making regarding sexual activity. This appears to have been the case for Mrs. Rayhons. There are several issues, however, when applying this framework to sexual decision-making. First, there are no consensus guidelines for determining capacity to consent to sexual activity. Second, decisions about with whom to have a sexual relationship are inherently different from medical decisions. For instance, medical decisions are generally made with attention to logic and reasoning whereas sexual decisions sometimes proceed with little attention to pros and cons or future implications.

Formal assessment of capacity may be a useful tool in the initial evaluation of residents for the ability to consent to sexual activity in the nursing home. These assessments, however, should not necessarily drive the definitive ruling about whether a resident can engage in sexual activity as this appears to be a medicalization of an essentially personal decision. To support freedom in decision-making for residents with dementia, nursing homes can adopt a more person-centered approach by which the nursing home works to advocate for the personal needs of the resident as opposed to gate-keeping resident’s decisions. From this perspective, every attempt is made to prevent foreseeable and unreasonable harm but there is acknowledgement that decisions regarding sexuality carry inherent risk and that older residents with dementia should not necessarily be held to a higher standard of decision-making than younger individuals.

Image Credit: Photo by Unsplash. Public Domain via Pixabay.

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