The Triple Helix at Brown: Spring 2015 by Brown Triple Helix

SPRING 2015

Lemurs & Racehorses:

A DISCUSSION ON SCIENTIFIC LEGACY JACOB KIRSCHENBAUM

THE (A)SYMMETRIC VITRUVIAN MAN

MAKE LOVE, NOT WAR: A LESSON FROM BONOBOS

EHR: RESTRUCTURING US HEALTHCARE

BEATRICE SENOCAK // 18

CASSANDRA PESTANA // 8

KAVIA KHOSLA // 26

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berkeley cambridge harker harvard jhu

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about

staff president Rachel Occhiogrosso editor in chief Eric Bai Alexander Meehan finance Connor Shinn outreach Justine Palefsky Rudy Chen science policy Lily Chan Elena Suglia epublishing Rachel Occhiogrosso managing editors Oliver Lyman marketing Dana Schwartz Cindy Abarca webmaster Adam Scherlis layout Kaley Brauer editors Hank Baker Jordan DeLoach Lucy Zhou Mali’o Kodis

Methma Udawatta Russell Shelp Sam Kortchmar Sarah Lee

The Triple Helix is an independent, studentrun organization committed to exploring the intersection of science and society. We seek to examine the socioeconomic, moral and environmental implications of scientific advances, and to highlight the surprising ways that science can affect our ideas of humanity. The Triple Helix has an international scope, with chapters all over the globe, ranging from Berkeley to Yale, to Cambridge, Melbourne and the National University of Singapore. You are currently holding a copy of one of the Brown chapter’s biannual magazines. Inside, you will find a collection of articles written, edited & designed by students here at Brown.

writers Jacob Kirschenbaum Sophia (Seon Yeong) Park Miranda Norlin Shannon McCarthy Beatrice Senocak Audrey Lee

Priya Patel Kavia Khosla Lucy Van Kleunen Cassandra Pestana Nicholas Mankiw

Logo design by Chen Ye ‘17. Cover art by Kaley Brauer ‘17, using images of bacteria species that were propagated by Eli Block RISD ‘16.

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Dear reader, To properly convey to you how happy we are to share this work is a lofty goal. It’s unfortunate that we can’t include a snapshot gallery of the writing meetings, design sessions, email correspondences, and the many other moments our staff shared in putting this edition together. The late nights and long hours are well worth the effort, however, to bring you this magazine. Our publication is a most Tysonian work. (Tysonian, of course, deriving from Neil deGrasse Tyson, director of the Hayden Planetarium and popular scientist extraordinaire - let’s pretend this is a word for a moment.) Like Dr. Tyson, we want to share with you scientific matters of such importance to us that we see no other option than to write and illustrate this edition. From hiding behind our smartphones to learning from monkeys, we hope the ideas in these articles inspire you to tell the world about the things that are important to you. The roots of The Triple Helix continue to spread through the Brown community. The bright, bursting colors of our previous edition are widely recognized (as is our beloved North Atlantic whale Churchill on page 33), and our blog continues to gain readership. Our organization now involves people of all talents and interests around College Hill. We’re thrilled to bring you their ideas and efforts in the coming pages. Russell Shelp Managing Editor

FROM OUR HEADQUARTERS One important mission of the The Triple Helix is to get our readers thinking critically about the ethical impact of emergent technologies on public policy. There are a number of organizations that do this, but our efforts are unique because we are an independent, student-run publication. We offer an unbiased report on the topics that are the most interesting to us, the young people of this generation. I imagine that years in the future, these articles will serve as a valuable record of the youth perspective on great scientific debates of our time.

Even as The Triple Helix continues to grow and expand in new directions, the core of what we do remains the same: creating an open forum for discussion and education. We must embrace the path forward and expand our readership by broadening our reach. Let us harness the power of social media to promote our original works so that more people can participate in the conversation. We are doing well, but I know we can do even better. It has been a privilege to serve with my dedicated team over the past eight months. Together, we have laid the foundations for success to build on in the coming months. To our readers and our Triple Helix Members, I thank you for your continued support and participation. To our graduating alumni, I look forward to hearing of the accomplishments of our TTH family. Please keep in touch so that we may celebrate your successes with you! Finally, I want to thank each of you for a wonderful term. Mirulda CEO

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contents

SPRING 2015

8 MAKE LOVE, NOT WAR

12 ADHD

A Lesson From Bonobos CASSANDRA PESTANA

Why Kids Today Can’t Stay Still

18 (A)SYMMETRIC VITRUVIAN MAN An Overview of Brain Lateralization and Asymmetric Brain Functionality

NICHOLAS MANKIW

BEATRICE SENOCAK

FEATURES ON THE COVER

LEMURS AND RACEHORSES: A DISCUSSION ON SCIENTIFIC LEGACY

Jacob Kirschenbaum

26 EHR

Cognitive Human (Un) Enhancement? AUDREY LEE

Restructuring US Healthcare through Information Technology

30 BEHIND THE CONSENT FORM What We Shouldn’t Miss From the SUPPORT Controversy

KAVIA KHOSLA

34 A NEW AGE OF DECEPTION

How Technology is Changing the Face of Lying SHANNON MCCARTHY

40 NATURAL WORM CONTROL The Potential Use of Medicinal Plants

SOPHIA (SEON YEONG) PARK

46 LIP LIFT

MIRANDA NORLIN

Can Cosmetic Surgery Increase One’s Happiness? PRIYA PATEL

Exploring the Earthy Scent of Wet Dirt LUCY VAN KLEUNEN

To highlight the creative energy inherent in the realms of art and science as well as the importance and power of conveying scientific concepts visually, we present Equilibrium: a showcase of student artwork. This edition’s series of Equilibrium pieces all come from Mary O’Connor ‘16. Look for these pieces in between the articles!

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Lemurs & ARTWORK Kaley Brauer ‘17 Eli Block RISD ‘16

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s & Racehorses:

A DISCUSSION ON SCIENTIFIC LEGACY JACOB KIRSCHENBAUM ‘17

There’s a New York Times article taped on the door of my refrigerator, and it’s been there for about seven years. It’s tucked away neatly in the bottom left corner, outlasting all the report cards, wedding invitations, and family photos. The piece of paper that was once a pleasant off-white has turned a musty yellow, and its corners have curled upwards so that, in order to read the article, I have to hold it down at the edges. It’s about a racehorse named Barbaro, and I never let a day pass without stopping in front of the fridge to remind myself of who he was. I’m sure you don’t remember Barbaro. He was the centerpiece of one of those fad news stories that held the attention of our nation’s citizens back in 2007. His struggle through a broken leg that culminated with a heartbreaking euthanizing struck a chord with people around the country, and Jeff Neuman’s Times article, “Why We Mourn Barbaro” explains why we had such a human reaction to the death of a horse. The piece was almost tonguein-cheek, as Neuman compared Barbaro’s lack of both public scandals and poor role modeling to the plethora of such among our nation’s most beloved athletes, concluding with, “He trained, ate and slept. He ran his races, gave his best effort, accepted plaudits graciously, went back to his stall and prepared to do it again the next time out. He never fathered multiple offspring out of wedlock. Alas” [1]. For me, he’s a re-

minder that greatness can be found in the most ordinary and humble of lifestyles, and that sometimes, those unappreciated can bring us the most value if we only give them a chance. When I saw the title, “Allison Jolly, Who Discovered Female Dominance in Lemurs, Dies at 76” in a recent Times edition, I almost laughed out loud. Female dominance in lemurs is not only one of the most oddly specific areas of study, but also one that seems to have almost no societal relevance, let alone merit for memorial. As you can probably guess, I was wrong. Reading the article out of curiosity, I immediately saw Barbaro in Jolly. She was a racehorse of a scientist who, unlike her colleague Jane Goodall, never became a household name among Americans, despite her groundbreaking research in the field of evolutionary biology [2]. She was the first Western researcher to explore Madagascar, and her work provided important results on how we understand evolution as a product of environmental factors. Because Madagascar is an island that, geologically speaking, recently broke off from Africa, it serves as a evolutionary time capsule, or as Jolly puts it, the island allows us to observe “what happens when time has broken its banks and flowed to the present down a different channel” [3]. Her most famous fieldwork focused on the behavior of lemurs and how their social organization compares to that of their mainland

counterparts – giving us important insights to the cogs of evolution’s machinery. As I dug deeper into Jolly’s legacy, and I don’t use that term lightly, I found that she had published numerous books on Madagascar, exploring all facets of the country and its inhabitants. She pushed the envelope for women in science her entire life, especially as a publisher and writer of her own work, yet, at the time of her death, most people in the country probably didn’t know her name. I’m not writing this to rant about why we mourn Barbaro and not Jolly – that would be trite, and has more to do with media influences and American social values than anything else. I was curious to see if Jolly really did leave a legacy, and as I searched through her work, I began to consider larger questions about scientific legacy in a more abstract sense. If a scientist fails to leave a legacy, what use was his or her work? More generally, if we cannot successfully record our ideas and advancements into pages of history, what use is any scientific achievement? As such, I decided to explore this notion of legacy and what it means to leave one in the scientific community. I use Jolly as a case study, but the issues discussed have implications outside of Jolly’s life work. Why choose Jolly? The answer has more to do with her similarities with our good friend Barbaro than anything else.

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DEFINITION OF LEGACY What does it mean to leave a scientific legacy, and how do we determine who leaves one? Should we limit the group to those who have won a certain award, like the Nobel Prize? Or should the true legacies be reserved for those who have made their way into the mainstream zeitgeist at some point in their lives instead of bringing Mozart to the masses, perhaps bringing Newton to the neophytes? To answer these questions, I sat down with someone who commands an undeniable scientific legacy, Brown’s very own Nobel Laureate Leon Cooper. From a pragmatic perspective, the scientist has to contribute to an ongoing problem of the day, Cooper said. This may seem like a moot point, since a scientist who works on a problem that is not relevant, or has already been solved, would certainly not be in consideration for a substantial scientific legacy. However, there is a deeper truth to this simple statement, as it implies that scientists have to be aware of the rest of their community – there is a degree of

awareness that a scientist must have in order to leave a lasting legacy. Conversely, the public also has to be aware of the work, Cooper said, in the most basic of ways. Whether the researcher publishes his or her work within the specific discipline the work concerns itself with, or if the researcher chooses to publish a book for more mainstream audiences, the work must be made public in order to be considered something that contributes to an individual’s legacy. This makes the job of researchers twofold – do the work, then communicate the ideas effectively. The concept of a paradigm shift has become essential to discussion of the history of science ever since Thomas Kuhn published his The Structure of Scientific Revolutions. Kuhn argues that scientific progress is driven by periodic shifts of paradigm, which are described as complete reformations or refutations of once accepted notions or methodologies. Going into my inter-

view with Professor Cooper, I planned on focusing on this concept of a paradigm shift, and how it relates to scientific legacy. Contrary to my initial instincts, however, Cooper thought that not all legacy-deserving work necessarily constitutes a paradigm shift: “behind every major discovery or theory, there are a thousand smaller pieces behind it.” These smaller pieces of work are just as important, and this is where we find our Barbaro within a seemingly distinct conversation about scientific legacy. Barbaro’s best quality – his ability to put in hard work, day after day, not always necessarily winning the races or receiving the recognition he deserved – is precisely the quality that scientist’s must possess if they hope to leave a legacy. To contribute to solving a problem of the day in a qualitatively rigorous and socially contextualized manner is all a scientist can do, and if he or she is successful at it, like Jolly, the work, can be remembered and utilized in later generations.

“

Behind every major discovery or theory, there are a thousand smaller pieces behind it. Leon N. Cooper

”

PHOTO Mike Cohea/Brown University

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QUALITY OF WORK Of course, what defines “qualitatively rigorous?” Put simply, a scientist’s work must have a certain merit to it to be considered a contributor to a legacy, defined by an integration of outside information and unification with more general theories. We all know that great work requires collaboration, but behind this simple mantra is a larger implication regarding scientific legacy– if we remain within our own area of expertise, why would anyone else care? Researchers must be able to integrate the work of others in their own arguments in order to strengthen them and solidify their legacy. Jolly does this throughout her books, but perhaps the simplest example is that of plate tectonics. Jolly’s books were written in the 1970s,

only about a decade after the geological community accepted the theory of plate tectonics as valid. Her entire argument concerning the importance of Madagascar as an evolutionary time capsule hinges on the concept of plate tectonics, as one must accept that Madagascar was once a part of Africa [3]. Her ability to utilize recent advancements in separate fields of study qualifies Jolly in this category, and shows us how a multi-disciplinary approach is often successful. If you’ve ever been to a physics class, or listened to Neil DeGrasse Tyson speak, it’s hard to ignore the importance of unification in science. The ability to take specific work and apply it to larger, more general theories and concepts is one of the main goals of scientific in-

quiry [4]. Not surprisingly, Jolly does just that. Her work is not important because we learned more about behavioral patterns of Malagasy wildlife, or because she documented hundreds of new species of plants and animals. Her work is important because it changes our understanding of a larger, more general theory – evolution – this was only accomplished because Jolly believed that her specific work had larger implications, and she was able to make those connections. To consider the social hierarchy of lemurs is almost unimportant if we fail to consider the corresponding hierarchies of primates on other parts of the globe in the context of their evolutionary timeline, which is exactly what Jolly did [2].

CONTEXTUALIZATION The ability to contextualize work contributes equally to a scientist’s legacy as the merit of the specific work. To have both a cultural and social understanding of one’s work are pillars of scientific contextualization, and therefore, one’s legacy. If a researcher has no concept of how his or her work affects the cultural identity of any specific society, or how his or her work is related to this culture, how can he or she expect people to remember his or her work? Herein lies the relationship between cultural awareness and scientific legacy, and Jolly is certainly no exception to this rule, as you probably guessed. Jolly carefully pulls a thread of cultural relevance through her tour de force, A World Like Our Own, and, at points, reading the book is less like reading a field journal and more like reading a sociological analysis of Madagascar. Over the course of the book, Jolly meets with various local scientists who aid her in her pursuit

of funding and support for her work, including a Dr. Étienne Rakotomaria, who says, “[Most people] know that Malagasy nature is a world heritage. We are not sure that [they] realize it is our heritage” [3]. Jolly clearly makes an effort to convey to her reader the deeper personal and cultural issues that arise when discussing conservation efforts and wildlife preservation, and she captures this quality of her work most succinctly in her dedication, where she writes: “For Richard, who said, ‘Tell the whole story – ecology with people, not just your animals’” [3]. Similarly, if a scientist cannot clearly determine what the social implications of his or her work are, he or she cannot hope to be remembered for very long. The ability to make SPRING 2015 || THE TRIPLE HELIX

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people understand why one’s work is significant is perhaps one of the most important qualities a scientist can possess. In Jolly’s case, she, very early in her book, is able to outline exactly why her work is relevant, as she generalizes the questions she deals with in her work: “in the end, the question ‘Is conservation of nature worthwhile in Madagascar?’ becomes simply ‘Is conservation worthwhile?’ and the greater question, ‘If we destroy nature, can we save humanity?’” [3]. Here, Jolly explicitly states why her work is not just important to the people of Madagascar, but that it serves as a microcosm of our global conservation efforts, thus making her work important, relevant,

“

and contribute to her legacy. Allison Jolly was an exemplary scientist in her ability to conduct high quality work and successfully contextualize for the public. She was exceptional at what she did, did it for some kind of pure passion for the subject, and continued to work with a stalwart dedication throughout her life. These qualities should have merit in our society – people who are good at what they do and then actually execute that skill to the most exemplary degree should be remembered. That’s why we mourn Barbaro, and that’s why we should mourn Jolly. She never wrote a national bestseller, and she never hosted

People who are good at what they do and then actually execute that skill to the most exemplary degree should be remembered. That’s why we mourn Barbaro, and that’s why we should mourn Jolly.

EDITOR Hye In Sarah Lee

“Cosmos.” She never appeared as an animated character on PBS educational programming, and she was never interviewed by Jimmy Kimmel or Jon Stewart. She observed, recorded, hypothesized, reasoned, questioned, concluded, and went back to her tent in the middle of the Malagasy rainforest and prepared to do it the next day. To satisfy concerns that her Madagascar legacy is not apparent in our everyday lives, one must look only at a certain animated movie franchise with Ben Stiller and Chris Rock, a franchise that has grossed almost $2 billion worldwide - almost none of which, unfortunately, has been donated to conservation efforts in Madagascar. Alas.

”

REFERENCES [1] Neuman, Jeff. Why We Mourn Barbaro. 2007 Feb 1. [2] Vitello, Paul. Allison Jolly, Who Discovered Female Dominance in Lemurs, Dies at 76. 2014 Feb 18. Available from http://www.nytimes. com/2014/02/19/us/alison-jolly-76-dies-discovered-female-dominance-in-lemurs.html?_r=0

[3] Jolly, A. A world like our own: man and nature in Madagascar. New Haven: Yale University Press; 1980. [15] Cooper, Leon. Interviewed by Jacob Kirschenbaum. 17 March 2014. [cited 21 March 2014] [16] Weinberg, Steven. The Search for Unity. Daedalus. 106(4). p. 17-35

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PHOTOS Kaley Brauer â&#x20AC;&#x2DC;17

MAKE LOVE, NOT WAR:

A Lesson from Bonobos CASSANDRA PESTANA â&#x20AC;&#x2DC;15

The human race, similar to our animal counterparts, is brimming with acts of violence, greed, competition, and ruthlessness. The animal kingdom often suggests that aggressive and defensive behaviors are necessary for survival and successful reproduction. However, is there a more peaceful way to succeed evolutionarily? Study of bonobo society suggests that there is.

Humans share 98% of their DNA with two species of the genus Pan: traglodytes (chimpanzees) and paniscus (bonobos). Surprisingly, these apes are more closely related to us than they are to gorillas, their more phenotypically similar relative [1]. Despite their genetic similarity however, chimpanzees and bonobos are polar opposites socially [2].

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Social Poles Bonobos are known for their gregarious life-style, in which sexual behaviors, both hetero and homo, are common and serve many functions [3][4]. They lack a pronounced dominance hierarchy, making for a nearly egalitarian society, although females hold more influence over the group than do males [5]. Excessive aggression is not

common among bonobos [3], but the same cannot be said for their close relative the chimp. Chimpanzees live in patriarchic societies in which aggression and violence are not uncommon [3][6]. They’ve been described as “bloodthirsty killer-apes,” due to their involvement in war, tor-

ture, infanticide, and cannibalism [7]. Frans de Waal, ethologist and primatologist, concludes that “the chimpanzee resolves sexual issues with power, while the bonobo resolves power issues with sex” [8]. So, which one can humans best identify with? Or further, which relative should we identify with?

“Mock Man” It wasn’t until 1916 that bonobos were recognized as a separate species [1]. Chimpanzees, however, were named more than a hundred years earlier in 1738 [9]. During this time, the chimpanzee’s aggressive and violent behavior served as reinforcing evidence that violence is innate to human nature. In fact, the word chimpanzee itself means “mock man” [9].

Would societal understanding of human evolution today be different had bonobos been discovered prior to chimps? De Waal argues that “reconstructions of human evolution might have emphasized sexual relations, equality between males and females, and the origin of the family, instead of war, hunting, tool technology, and other masculine fortes” [10]. Study of bonobos should redirect our interpre-

tation of our own evolution and be treated as newfound evidence that homosexual behaviors, female equality, and promiscuity can be evolutionarily advantageous. The discovery of the bonobo marks an expansion of awareness of our predispositions. We can choose which relative we use to justify our behaviors. We can choose which ape deserves the name of “mock man.”

The Role of Homosexuality and Female Influence in Controlling Aggression Homosexuality has been classified as a paradox, due to its inability to lead to reproduction. It has therefore been argued that homosexuality should not exist [5][11]. This assumes that all sexual behavior exists for the sole purpose of reproduction. However, the correlation between heterosexual sex and reproduction in humans is nearly zero [12]. In other words, we have much more sex than we do children, suggesting that sex serves as more than just a reproductive mechanism, but could perhaps be done for pleasure or for social bonding.

bonobos often participate in face-toface copulation. It is hypothesized that the frontal orientation of the vulva and clitoris in female bonobos was adapted for this position [5], allowing for more personal, intimate, and pleasurable experiences than traditional mounting positions. They also exhibit a diversity of erotic contacts including genital rubbing, sporadic oral sex, massage of another’s genitals, and intense tongue-kissing between members of all sex [5][4], implying that genital stimulation serves both hedonic and reproductive urges.

Further supporting this hypothesis,

Bonobo behavior further suggests that

homosexuality plays additional alternate roles in society – aside from that of pleasure – such as reconciliation, mate attraction, tension regulation, and social bonding [13]. Hohmann et al. find that post-conflict genital contacts are more common than pre-conflict, suggesting reconciliation is a motivator for sexual behaviors. They also found that rates of genital contacts increase during contexts of high tension, such as when food is present but scarce, and that they are most common between females, enabling them to band together and overcome the more individually powerful sex.

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ARTIFICIAL SISTERHOOD In order to maintain significant amounts of control and influence over males, female bonobos use homosexual behavior to create a sense of “artificial sisterhood” [5][6]. These homosexual behaviors allow them to form close social relationships with which to promote cooperation against the physically stronger males [14]. The feminist movement is a human example of women coalescing for equal rights and opportunity. It wasn’t until women united through social bonding and understanding that they were able to overcome male repression of their rights and capabilities as voters, workers, and influencers. Homosexual behaviors are the basis of this social bonding in bonobo society.

EVERLASTING ESTRUS Female bonobos also protect their social standing against stronger males by extending estrus (periods of high levels of fertility) [6]. According to the amicable trade-off hypothesis, males are less aggressive with females who are sexually attractive [15][16]. Since amicable social relationships between males and females of this species are critical for mating success, males are encouraged to reduce their levels of testosterone in order to lower their levels of aggression and thus appeal to females though peaceful interactions, such as grooming [15]. Therefore, the extension of estrus allows for the prolonging of male cooperation and respect [4]. Similarly, it should be safe to argue that if women refrain from loving and

reproducing with men who do not support their rights as equal human beings, then those beliefs and traditions will wane from society. Women, like female bonobos, should demand amicability, fairness, and equality from their male counterparts that want to pass their genes and traditions on to the next generation.

AGRESSION UNCHECKED Unlike that of bonobos, chimp social structure is dictated by male aggression, suggesting that if females fail to stand together or to be highly selective in their choice for partners, aggression will continue unchecked. Because female chimpanzees do not have the same opportunities to stand up against male dominance due to their inability to socially bond in a significant way [6], male aggression runs rampant and dictates the social structure and mating success [3][6]. Nathan W. Bailey and Marlene Suk hypothesize that “same-sex sexual behavior [in bonobos] provides the glue that establishes, maintains, and strengthens social relationships” [17]. Without this glue in chimp society, female power is unable to compare to that of males, enabling males to continue imposing their decisions on females without their consent or input.

WAYS TO ALLEVIATE TENSION Bonobos also successfully use different forms of sex to alleviate tension, therefore maintaining low aggression [4]. De Waal notes that anything that arouses the interest of more than one bonobo at a time tends to result in sexual contact [5]. Jealous males have been

observed chasing another male away from a female and then reuniting and engaging in scrotal rubbing. Similarly, if a female hurts an unrelated juvenile, the mother of that juvenile may react instinctually by lunging at the aggressor, an action immediately followed with genital rubbing between both females [5]. When two groups unexpectedly encounter each other they peacefully mingle and engage in mutual sex and grooming. In these potentially tense situations, bonobos partake in kissing, genital rubbing, and copulation in order to reconcile aggressive behaviors and avoid competition or hostile encounters that could lead to injury and destroy social peace [5][18]. When faced with potential competition over food resources, territory, or partners, chimpanzees respond with increased levels of testosterone, which lead to a “high-power motive,” while bonobos respond with increased levels of cortisol, which increases stress and results in a more passive coping style [19]. Sexual acts, unlike violence, tend to reduce stress and this hormonal difference is what enables bonobos to instinctually avoid conflict and violence. Some may argue that bonobos are compulsive sexual beings and that homosexuality exists merely because they are unable to control their urges. However, while bonobos engage in sexual behaviors between most members of the group, they do not perform acts of incest [5]. Incestuous relationships lead to the loss of genetic variation, which can be detrimental to a species. This suggests that although bonobos are creatures of sexual tendencies, they still obey the “laws” of evolution and avoid evolutionarily disadvantageous sexual behaviors that might be detrimental to their gene pool. Together, these results indicate that sexuality can serve as a peaceful alternative to aggression for resolving social tensions.

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War vs. Love For chimpanzees, aggression is used to settle power disputes and to gain control of important resources [19]. When humans use violence to settle similar issues, there are serious repercussions. In his article in Time Magazine titled “America’s Medicated Army,” Mark Thompson claims that “medication can alleviate some debilitating and nearly intolerable symptoms of combat and

operational stress injuries” and “helps restore personnel to full functioning capacity” [20]. It has also been noted that the “repeated deployments to the warzones contribute to the onset of mental-health problems,” such as post-traumatic stress disorder (PTSD) [20]. The majority of humans appear unable to cope with the guilt and memories of violence and aggression,

without the help of therapy and drugs. If this is true, and medication such as Prozac is necessary for full function in combat and recovery afterward, then perhaps humanity should find an alternate way of settling disputes – one with less detrimental psychological consequences. Perhaps bonobos can teach us a thing or two about love as a healthy alternative to war.

Conclusion Clearly humans can relate to both societies, as we demonstrate spiteful behaviors when angered and altruistic behaviors when empathizing [21]. Evolutionary biologists and behaviorists today are working to learn more about “what pushes humans toward either extreme” so that we can find “the key to a more peaceful existence for us all” [7]. If there is evidence of a peaceful society in which males and females live harmoniously, inevitable tensions are relieved through affectionate behaviors, and sexual behaviors of all

References

sorts are accepted, then it must be possible for us to choose to likewise make our society egalitarian and accepting. Not only does the natural evidence exist, but it exists in one of our closest living relatives. We can continue to emulate the killer-ape, the chimpanzee, or we can learn from the bonobo and, as Martin Luther King Jr. once said, “evolve for all human conflict a method which rejects revenge, aggression and retaliation. The foundation of such a method is love.” The choice is ours.

EDITOR Hank Baker

[1] Duke University. What is a Bonobo?. [Internet] [cited on 2013 October 21] Available from http://evolutionaryanthropology.duke.edu/research/3chimps/chimps-bonobos

[13] Hohmann G, Fruth B. Use and function of genital contacts among female bonobos. Animal Behaviour 2000; 60: 107-120.

[2] Public Broadcasting Service. Chimps and Bonobos Evolution: “Why Sex?” [Internet] 2001 [cited on 2013 October 21] Available from http://www.pbs.org/ wgbh/evolution/library/07/3/l_073_03.html

[14] Ralph T, Global Post. Study: Female bonobos have sexual relations with other females to boost their status [Internet]. 2012 March 1 [cited 2013 September 25]. Available from: http://www.globalpost.com/dispatches/globalpost-blogs/ weird-wide-web/study-female-bonobos-homosexual-relations

[3] Sommer V, Bauer J, Fowler A, Ortmann S. Patriarchal Chimpanzees, Matriarchal Bonobos: Potential Ecological Causes of a Pan Dichotomy, Springer 2011; 35:469-501. [4] Stanford BS. The Social Behavior of Chimpanzees and Bonobos, Current Anthropology 1998; 39: 399-417. [5] De Waal FB. Bonobo sex and society: The behavior of a close relative. Scientific American 1995; 58-64. [6] Furuichi T. Female contributions to the peaceful nature of bonobo society. Evolutionary Anthropology 2011; 20:131-142.

[7] Kirshenbaum S, National Public Radio. Do Bonobos And Chimps Offer A Path

To Understanding Human Behavior? [Internet] May 2012 [cited 2013 November 2] Available from http://www.npr.org/blogs/13.7/2012/05/07/152197388/ do-bonobos-and-chimpanzees-offer-a path-to-understanding-human-behavior

[8] Quammen D. National Geographic. The Left Bank Ape. [Internet] March 2013 [cited 2013 October 21]. Available from http://ngm.nationalgeographic. com/2013/03/125-bonobos/quammen-text

[9] Infoqis Publishing Co. Information and Facts about Chimpanzees. [Internet] 2009 [cited 2013 October 21]. Available from http://www.chimpworlds.com/

[10] Waal F, The New York Times. Bonobo: The Forgotten Ape. [Internet] 1997 [cited 2013 October 21]. Available from http://www.nytimes.com/books/first/d/ dewaal-bonobo.html

[11] Pope SJ. Scientific and Natural Law Analyses of Homosexuality, The Journal of Religious Ethics 1997; 25: 89-126.

[12] Benagiano G, Carrara S, Filippi V. Sex and Reproduction: an evolving relationship, Oxford Journals 2009; 16: 96-107.

[15] Surbeck M, Deschner T, Schubert G, Weltring A, Hohmann G. Mate Competition, testosterone and intersexual relationships in bonobos, Pan paniscus. Animal Behaviour 2012; 83:659-669. [16] Nature World News. Attractive Females Dominate the Social Circle: Bonobo Study. [Internet] 2013 July 16 [cited 2013 October 21]. Available from http://www. natureworldnews.com/articles/2986/20130716/attractive-females-dominate- social-circle-bonobo-study.html [17] Bailey NW, Zuk M. Same-sex sexual behavior and evolution. Trends in Ecology and Evolution 2009; 24: 439-446. [18] Hare B, Wobber V, Wrangham R. The self-domestication hypothesis: evolution of bonobo psychology is due to selection against aggression. Animal Behaviour 2012; 83: 573-585. [19] Wobber V, Hare B, Maboto J, Lipson S, Wrangham R, Ellison P. Differential changes in steroid hormones before competition in bonobos and chimpanzees, Proceedings of the National Academy of Sciences of the United States of America 2010; 107: 12457-12462. [20] Thompson M, Time Magazine. America’s Medicated Army [Internet] June 2008 [cited 2013 November 2] Available from http://content.time.com/time/magazine/article/0,9171,1812055,00.html [21] Whipps H, Live Science. The Evolution of Human Aggression [Internet] February 2009 [cited 2013 November 2] Available from http://www.livescience. com/5333-evolution-human-aggression.html

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AD ARTWORK Kaley Brauer ‘17 Mary O’Connor ‘16 12

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DHD Why Kids Today Can’t Stay Still NICHOLAS MANKIW ‘17

2 OPINIONS DOMINATE the debate about the rising diagnosis in ADHD. One claims that ADHD has become over diagnosed while the other claims that ADHD has become better diagnosed.

AN UNCOMMON OPINION is that societal changes have actually increased the number of children with ADHD.

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Attention-deficit hyperactivity disorder, or ADHD, is one of the most common mental disorders in children and young adults. Estimates based on epidemiologic surveys put the percentage of children with ADHD around 5-10% [1]. ADHD was not always this recognized, however, and there has recently been a rise in the diagnosis of the disorder. ADHD was commonly thought to be in 3-7% of children. Now a few select studies show that 15% of boys and 10% of girls will receive an ADHD diagnosis by high school [2]. Most studies support that 5-10% of children have ADHD [1]. People have different opinions on why there is this increase. The two most common ideas are that the disorder is becoming better recognized or over diagnosed, but both think there is not an actual rise in ADHD. The idea that ADHD is over diagnosed has significant flaws and does not accurately acknowledge the people that struggle with the disorder. The idea that ADHD is was previously underdiagnosed is correct that the disorder is becoming better recognized, but it is incomplete as it does not take into account changes in society which could impact the number of people with ADHD. Some background on ADHD is needed to understand the reasoning behind these opinions. ADHD has two general types: inattentive and hyperactive. Its diagnosis is based on a series of questions to determine whether the patient displays the symptoms of ADHD such as fidgetiness, difficulty remaining seated, forgetful, and impatience [1]. The clinician determines whether the symptom is severe or not and uses these judgments to determine if the child has ADHD and its severity. On the neurobiology side, people with ADHD are shown to have significantly smaller brain areas than that of those without ADHD, specifically, the caudate nucleus, cerebellar vermis, globus pallidus, and the corpus callosum [3]. The caudate nucleus and globus pallidus contain a high density of dopamine receptors. The primary purpose of dopamine is to mediate the reinforcement pathways in the brain, and the underlying problem for many people with ADHD is a problem with the reinforcement pathways [3].

CONTRADICTORY OPINIONS ON ADHD An opinion over-popularized by the media about the rising diagnoses is that ADHD is not actually that common or not even a real disorder [2]. The main basis for this opinion is the subjectivity in diagnosing ADHD and that for a long time children with ADHD were simply unruly children[10]. Since it is based on the clinicianâ&#x20AC;&#x2122;s opinion rather than on a strict test, a diagnosis is more subjective than objective. According to this opinion, drug companies use the subjectivity to their advantage in order to sell more ADHD medications [10]. An even more extreme view is that ADHD does not actually exist, and the

wealthy created ADHD as an excuse to give their children super drugs to perform better in school. The problem with this opinion is that it does not recognize the evidence that there is a neurological basis for ADHD. The media has highly publicized this side of the debate and latched onto a few inflammatory, inaccurate statistics. The counter opinion is that ADHD was previously underdiagnosed and that people with a serious disorder were unfairly labeled as deviant [1]. This opinion is supported by epidemiologic studies showing that around 5-10% of

the American children population has ADHD. The 10-15% were simply small pockets found in studies of limited size. With regard to drug companies, some believe that what they do in raising awareness about ADHD is actually beneficial to the population. Without this publicity, many children would go undiagnosed and continue to struggle [1]. The rising diagnoses are then not something to be concerned about but rather good news. This opinion has many merits and is far more accurate than the opinion that ADHD is overdiagnosed, but it overlooks certain arguments.

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POSSIBLE FACTORS FOR A RISE IN ADHD An uncommon and unstudied opinion is that there are a growing number of people with ADHD. This would have to be caused by some change in society that has made it more conducive towards ADHD. The problem with supporting this opinion is that ADHD is a heterogeneous disorder and as such there is no single pathway towards ADHD [4]. Currently, researchers believe that genetics plays a significant role in a person getting ADHD [4, 5]. Specifically, the dopamine transmitter gene, DAT1, and dopamine receptor gene, DRD4, are recognized to be the most common susceptibility genes. Mutations in these genes is a contributing factor to the decreased brain size in the caudate nucleus and globus pallidus, the significance of which was mentioned above. Even though there is a significant amount of evidence that ADHD is genetic, not everyone with ADHD will necessarily have these mutations and not everyone with these mutations will have ADHD. Because of this, scientists still think that ADHD is partially caused by environmental or social factors. Researchers, however, cannot be sure if these factors actually cause ADHD and its severity or whether there is simply a correlation [4]. Some of these possible environmental factors are video game addiction, childhood anxiety disorders,

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bullying victimization, and childhood family dynamcis. Video game and internet addiction directly correlate with the severity of ADHD [6]. Video games incentivize the player to get to the next level or get another achievement, and the game then provides an immediate reward when completed. This activates a striatal dopamine in the caudate nucleus release [6]. Continued video game use could reinforce the pathway leading to severe ADHD as well as video game addiction. It is not clear whether video games actually cause ADHD or whether people with ADHD are attracted to video games as they provide immediate gratification [6]. Some childhood anxiety disorders can lead to ADHD. Social phobia and Separation Anxiety Disorder (SAD) especially show direct correlation with later ADHD [7]. It is not clear exactly what the biological connection between social phobia and ADHD is. Bullying victimization is also positively correlated with ADHD, but the connection is not clear [8]. Scientists hypothesize that it may be connected through social phobia [8]. Early relationships between child and parent affect the development of children and have an impact on childhood ADHD. It is true that childhood ADHD can put strain on the parent-child relationship exacerbating the situation [4]. Pathogenic care, severely negligible care, towards a child also can lead to Reactive Attachament Disorder (RAD) which

has similar symptoms to and the same treatment as ADHD [9]. All of these environmental factors are related to ADHD and rises in them could either lead to or signal a rise in ADHD. Four major environmental factors were shown to affect ADHD video game addiction, other anxiety disorders, bullying, and changing family relationships. More people are addicted to the internet and video games, mainly because they have become more easily accessible. According to one study “14% of children and 20% of adolescents screened positive for excessive internet use” [6]. Compare this to the 10% of children with ADHD and remember that internet and video game addiction correlated with the disorder. Video games could potentially have caused more people to have ADHD, or they could have caused minor ADHD to become more severe and then more likely to be diagnosed. The next two causes closely tie into this idea. Both have become prevalent due to the internet. One study shows that 73% of Americans teens use social media which is an 18% increase from 2006. Social media sights have been both a playground for bullies and an anxiety producing factor in some people’s lives [11]. Anxiety can lead to ADHD. Bullying can lead to anxiety and ADHD.

An uncommon and unstudied opinion is that there are a growing number of people with ADHD. This would have to be caused by some change in society that has made it more conducive towards ADHD.

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CONCLUDING REMARKS The most commonly accepted cause by the scientific community is then that ADHD is becoming better recognized by clinicians and therefore people receive better diagnoses. But it is also likely that the changes in the environment mentioned above do have a negative effect on children and cause some rise in ADHD.

REFERENCES [1] Wozniak J. Interviewed by: Mankiw N W. November 2, 2013 [cited November 11, 2013]. [2] ] Schwarz A, Cohen S. A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise [Internet]. March 31, 2013 [cited September 20, 2013]. Available from: http://www. nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=all&_r=1&. [3] Tripp G, Wickens J R. Neurobiology of ADHD. Neuropharmacology 2009; 57 : 579-589. [4] Thapar A, Cooper M, Eyre O, Langley K. Practioner Review: What have we learnt about the causes of ADHD? J of Child Psychology and Psychiatry 2013; 54(1):3-16. [5] Sharp SI, Mcquillin A, Gurling H. Genetics of attention-deficit hperactivity disorder (ADHD). Neuropharmacology 2009; 57(7-8):590-600.

EDITOR Jordan DeLoach [7] Bittner A, Egger HL, Erkanli A, Costello EJ, Foley DL, Angold A. What do childhood anxiety disorders predict? J of Child Psychology and Psychiatry 2007; 48(12):1174-1183 [8] Unnever JD, Cornell DG. Bullying, Self-Control, and Adhd. J of Interpersonal Violence 2003; 18(129):129-147. [9] Dahmen B, P端tz V, Herpetz-dahlmann B, Konrad K. Early pathogenic care and the development of ADHD-like symptoms. J of Neural Transmission 2012; 119(9):1023-1036. [10] Stolzer JM, The ADHD Epidemic in America. Ethical Human Psychology and Psychiatry 2007; 9(2):109-116. [11] Miller M, With increased social media use comes increased social anxiety. 2013 Jul 3.

[6] Weiss MD, Schibuk H, Allan BA, Saran K, Baer S. The screens culture: impact on ADHD. Springer Open Choice 2011; 3(4):327-334.

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The (A)symmetric

Vitruvian Man: An Overview of Brain Lateralization & Asymmetric Brain Functionality BEATRICE SENOCAK ‘15 Leonardo Da Vinci’s Vitruvian Man, the iconic illustration of the Renaissance period, depicts two superimposed positions of a male body centered within both a circle and a square. The illustration is named in honor of Marcus Vitruvius Pollio, an influential Roman architect who considered the human body to be an example of architectural perfection and suggested that the symmetries of the human body should govern the way architectural structures were built [1]. Although Da Vinci’s drawing portrays the human body as perfectly symmetrical on the outside, this symmetry breaks down

on the inside, where the eye cannot see. In truth, the human body exhibits significant anatomical asymmetry. During embryonic development, the heart experiences a slight turn to the left side of the body, while the liver develops on the right and the two lungs grow into increasingly distinct structures [2]. Arguably, the most important example of asymmetry in the human body exists in the brain. A brief examination of the two halves of the brain – also known as the cerebral hemispheres – might initially cause one to consider that these structures are mirror images

of each other. Indeed, the hemispheres do not differ conspicuously in terms of structural features and total tissue weight. The distribution of brain tissue across the left and right cerebral hemispheres, however, reveals that there exists points of asymmetry between the two halves of this vital organ [3]. Such asymmetries give rise to functions that are associated with one side of the brain over the other, and make certain behaviors, including handedness and language, invaluable starting points in the quest for understanding the functionality of the human brain.

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Brain Lateralization The phenomenon of brain lateralization describes the asymmetry between the two hemispheres of the brain. As a result of lateralization, certain functions controlled by the brain are localized to one hemisphere over the other [4]. For example, in most people language-related functions are controlled by the left cerebral hemisphere. The dominance of the left hemisphere in language, however, does not render the right hemisphere insignificant in contributing to this function. In fact, the right hemisphere is thought to be important for processing tone of voice, humor, hesitation and figurative language [3]. The two hemispheres of the brain are extensively connected through a network of neuronal fibers called the corpus callosum, so that neither hemisphere works alone to control

a function. One of the most fundamental questions to consider while studying brain lateralization is why the brain prefers to organize itself such that neural networks controlling a certain function are located in one hemisphere instead of being spread out across the two hemispheres. Some neuroscientists argue that lateralization increases the brain’s efficiency and speed in executing functions, since communication within a hemisphere takes place more quickly than communication between two hemispheres, which involves sending information across the corpus callosum and then integrating input from both hemispheres [5]. Current research in the area of brain lateralization has also focused on determining mechanisms

underlying the brain’s asymmetric organization. Recent studies have suggested that brain lateralization might be driven by a collection of factors such as hormones, gender, fetal orientation in the womb, and genetic makeup [3]. Although there are extremely sophisticated ways of visualizing differences between the cerebral hemispheres of the brain and determining the functional outcome of these asymmetries, much remains to be understood about brain lateralization. The first step in studying this phenomenon in humans requires taking advantage of behaviors known to be controlled by a dominant hemisphere and therefore provide clues about the asymmetric organization of the brain [3].

Lateralized Behaviors: Language and Handedness LANGUAGE As indicated earlier, the left hemisphere is typically the dominant hemisphere in controlling functions related to language. This pattern of functionality was first discovered by the French neurosurgeon Paul Broca in the mid1800s, who noticed that patients suffering from aphasia [4] – the general term for conditions in which normal speech function is lost – had tumors in the left hemisphere of the brain. Although language is often considered to be dominantly controlled by the left

hemisphere, it can be lateralized to the right hemisphere or be controlled equally by both hemispheres as well. One of the early ways of determining a person’s hemispheric language dominance was the Wada test, developed in the 1950s. In this rather invasive procedure, a chemical called sodium amytal would be injected into the artery supplying blood to the hemisphere of the same side, inducing anesthesia and disrupting speech function in the hemisphere to which it was delivered [3]. Considering the complications that

could arise from chemically anesthetizing one half of the brain, it has been necessary to find ways of determining language-related asymmetry in less invasive ways. One method of determining language dominance is the dichotic listening test, in which experimenters can deduce hemispheric dominance of speech sound perception based on which ear processes simultaneous auditory stimuli more accurately [3].

HANDEDNESS Similar to language, handedness is also an asymmetric behavior. While language lateralization is observed in other species, such as passerine birds which produce song under the control of the left hemisphere [3], the strong bias for one limb over the other is uniquely observed in humans, even

when compared to other primates [5]. Comparing the incidence of handedness in humans and chimpanzees makes it likely that handedness in humans developed after the evolutionary divergence of humans and their primate ancestors [5]. It is thought that the lateralization resulting in handedness occurs during SPRING 2015 || THE TRIPLE HELIX

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THE PROBLEM WITH BEING LEFT-HANDED In the 19th century, an Italian physician by the name of Cesare Lombroso attempted to investigate the biological basis of criminality. Not surprisingly, left-handed individuals bore the brunt of Lombroso’s so-called scientific evidence, which associated lefthanders with a more primitive state of mind. In 1903, Lombroso wrote that, “…left-handedness, united with many other traits, may contribute to form one of the worst characters among the human species…” [8] adding, “…in early times, and still among people little civilized, such as Arabs the writing was preferably from right to left, which is the habit until corrected” [9]. Although Lombroso’s work is denounced as pseudoscience in the present day, until recently many researchers were seduced by the association of left-handedness with pathological conditions. In 1977, psychologist Theodore Blau concluded that “sinister children,” as he called them, were more vulnerable to mental illness and likely to experience academic and behavioral challenges [8]. Not so long after, neurologist Norman Geschwind wrote that left-handed individuals lived shorter lives and experienced delays in physical and mental development [8]. At the time, such claims on left-handedness were considered to be grounded in scientific evidence and started a new trend in many American and British schools, where left-handedness was increasingly considered a reflection of deviant personality. Often times, left-handed children were forced to convert to right-handedness. Some methods of ensuring this conversion were particularly brutal, as they involved restraining the child’s left-hand so as to keep it from being used [10].

ARTWORK Mary O’Connor ‘16 Anand Prahlad, tracing of da Vinci’s Vitruvian Man

Although left-handedness is relatively less common than right-handedness in the human population, the percentage of left-handed individuals has remained stable over the course of human existence, at roughly ten percent [2]. Archaeological analyses of cave paintings and artifacts such as hunting spears have confirmed the stability of this ratio [2]. While abnormal asymmetry of the human body can sometimes be indicative of a serious underlying condition – such as dextrocardia, in which the heart is unusually situated on the right – left-handedness is no longer considered to be a sign of an underlying pathology, but is accepted as a normal deviation from the usual asymmetry of human handedness [2, 11].

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the early stages of human development. The findings that embryos at seven weeks after conception generally have a more developed right hand and that 92% of fetuses which sucked their thumb in the womb preferred the right thumb over the left one, support the argument that handedness develops early on [5]. One study found that lateral-

ization of handedness might be driven by the LRRTM1 gene, implicating a genetic basis for right or left-handedness [6]. Considering the vague principles of brain lateralization, it would be logical to assume that handedness results from the lateralization of the motor

networks responsible for controlling hand movement [7]. Interestingly, the motor networks associated with handedness do not display the prominent left-right asymmetries that do language networks [3]. Handedness actually seems to be determined more so by asymmetries of language areas than by asymmetries of motor areas [7].

Language and Handedness: An Enigmatic Connection Paul Broca, the neurosurgeon who made the initial observations on language lateralization, also hypothesized that language dominance and handedness were correlated, such that a person’s handedness was opposite from the hemisphere controlling language [4]. Broca is famously quoted for

saying, “We speak with the left hemisphere” [5], and his ideas on lateralization gave rise to the Broca Rule, which predicted that right-handed individuals had left-sided language dominance and vice versa. Although studies have found that the correlate generally holds true for right-handers, it breaks down for left-handers. As it turns out, many left-handed individuals actually have left-sided language dominance, and significant percentages exhibit either right-sided or bilateral dominance [12, 13]. Although the correlation between lan-

guage and handedness is not perfect, it allows scientists and doctors to look at a person’s hands and make knowledgeable predictions on the organization of this person’s brain. Before the development of techniques such as fMRI, PET, Wada, and the dichotic listening test, neurosurgeons preparing to perform surgery on a patient often relied on the patient’s handedness as an external clue to the organization of their brain [4]. Unfortunately since not every brain – especially those belonging to left-handed individuals – is governed by Broca’s Rule, the hand-brain link must be used with caution.

The Origin of the HandLanguage Link Handedness and language are seemingly unrelated behaviors, which makes it surprising to observe a relationship between language dominance and handedness. Theories on the origin of the hand-language link indicate that these functions might not be all that unrelated after all. One theory explains the correlation by noting that both language and handiwork require fine motor skills and argues

that it would be more efficient for the brain to control these similar functions by having them located in one hemisphere [5]. Another theory suggests that language – a 200,000 year-old and therefore relatively recent development in the scheme of human evolution [3] – could be considered a parasitic system that invaded regions of the brain initially involved in controlling basic motor functions [14]. Theories attempting to understand the origin of the relationship between handedness and language dominance have provoked much thought on the evolution of verbal human language as well. A third theory on the origin of the language-hand link examines the role of gesture in human speech and hypothesizes that verbal language might SPRING 2015 || THE TRIPLE HELIX

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have evolved from a gesture-based language [3]. Several observations support this theory, such as the report that captive apes usually gesture with their right hand while making communicative sounds [3]. Studies of individuals who are blind from birth also found that these individuals use gestures while speaking. For example,

one study found that blind and sighted individuals alike tilted a C-shaped hand in order to gesture the pouring of a liquid [15]. Such findings imply that a gestural language might be hardwired in the brain and that our current verbal language may have evolved from a mode of language that once relied primarily on gestures. Finally, a fourth

theory, also known as The Right Shift Theory, argues that the connection between handedness and language dominance can be explained by gene which increases the probability of left cerebral dominance and left-handedness when expressed [5].

Conclusion The asymmetries between the two cerebral hemispheres of the brain seem to govern complex human behaviors such as language and handedness. Studying the cause and effects of structural and functional asymmetries in the brain can shed light not only on the evolution of the human brain, but also on how the brain works and why, in some cases, it does not work properly. Although it is unlikely that left-handedness is an indication of problematic brain asymmetry, the relationship between language EDITOR Lucy Zhou

dominance and handedness might be key in understanding disabilities such as stuttering and dyslexia. Most intriguing are accounts of patients reported to have developed speech impediments after being forced to convert handedness, generally from left-handedness to the more socially acceptable right-handedness [10]. It might be that forced conversion disrupts the synergy between language and hand areas of the brain, thus resulting in a deterioration of language function [10]. The

References

[1] Stanford University. Leonardo’s vitruvian man [Internet]. [cited 2013 Dec 12]. Available from: http://leonardodavinci.stanford.edu/submissions/clabaugh/history/leonardo.html [2] Klass P. On the left hand, there are no easy answers. The New York Times (USA) [serial online]. 2011 Mar 06 [cited 2013 Dec 13]. Sect. 18 and Under. Available from: http://www.nytimes.com/2011/03/08/ health/views/08klass.html [3] Toga AW, Thompson PM. Mapping brain asymmetry. Nat Rev Neurosci. 2003; 4(1): 37-48. doi:10.1016/10.1038/nrn1009. [4] Holder MK. What does handedness have to do with brain lateralization [Internet]. [cited 2013 Dec 12]. Available from: http://www.indiana. edu/~primate/brain.html [5] Papadatou-Pastou M. Handedness and language lateralization: Why are we right-handed and left-brained? Hellenic Journal of Psychology [Internet]. 2011 [cited 2013 Dec 13]; 8: 248-265. doi: 10.1080/1357650X.2011.615127. [6] Francks C, Maegawa S, Laurén J, Abrahams BS, Velayos-Baeza A, Medland SE, Colella S, Groszer M, McAuley EZ, Caffrey TM, Timmusk T, Pruunsild P, Koppel I, Lind PA, Matsumoto-Itaba N, Nicod J, Xiong L, Joober R, Enard W, Krinsky B, Nanba E, Richardson AJ, Riley BP, Martin NG, Strittmatter SM, Möller HJ, Rujescu D, St Clair D, Muglia P, Roos JL, Fisher SE, Wade-Martins R, Rouleau GA, Stein JF, Karayiorgou M, Geschwind DH, Ragoussis J, Kendler KS, Airaksinen MS, Oshimura M, DeLisi LE, Monaco AP. LRRTM1 on chromosome 2p12 is a maternally suppressed gene that is associated paternally with handedness and schizophrenia. Mol Psychiatry [Internet]. 2007 Jul 31 [cited 2013 Dec 13]; 12(12): 1129-1139. doi: 10.1038/sj.mp.4002053. [7] Siebner RH, Limmer C, Peinemann A, Drzezga A, Bloem BR, Schwaiger M, Conrad B. Long-term consequences of switching handedness: a positron emission tomography study on handwriting in “converted” left-handers. J Neurosci [Internet]. 2002 Apr 01 [cited 2013 Dec 13]; 22(7): 2816-2825. Available from: http://www.jneurosci.org/content/22/7/2816. long.

lateralization of the brain, it seems, reflects a balance of functionality assembled under the guidance of millions of years of human evolution.

[8] Konnikova, M. Sinister Minds: Are left-handed people smarter? The New Yorker (USA) [serial online]. 2013 Aug 22 [cited 2013 Dec 13]. Available from: http://www.newyorker.com/online/blogs/elements/2013/08/ psychology-are-left-handed-people-smarter.html [9] Kushner HI. The art of medicine: Cesare Lombroso and the pathology of left-handedness. Lancet [Internet]. 2011 Jan 08 [cited 2013 Dec 13]; 377(9760): 118-119. doi:10.1016/S0140-6736(11)60009-3. [10] Kushner HI. Retraining left-handers and the aetiology of stuttering: The rise and fall of an intriguing theory. Laterality [Internet]. 2012 [cited 2013 Dec 13]; 17(6): 673-693. doi: 10.1080/1357650X.2011.615127. [11] Deep-Soboslay A, Hyde TM, Callicott JP, Lener MS, Verchinski BA, Apud JA, Weinberger DR, Elvevåg B. Handedness, heritability, neurocognition and brain asymmetry in schizophrenia. Brain [Internet]. 2010 May 31 [cited 2013 Dec 13]; 133(10): 3113-3122. Available from: http://brain.oxfordjournals.org/content/133/10/3113.long [12] Knecht S, Dräger B, Deppe M, Bobe L, Lohmann H, Flöel A, Ringelstein EB and Henningsen H. Handedness and hemispheric language dominance in healthy humans. Brain [Internet]. 2000 Aug 17 [cited 2013 Dec 13]; 123(12): 2512-2518. Available from: http://brain.oxfordjournals. org/content/123/12/2512.abstract [13] Khedr EM, Hamed E, Said A, Basahi J. Handedness and language cerebral lateralization. Eur J Appl Physiol [Internet]. 2002 Jan [cited 2013 Dec 13]; 87(4-5): 469-473. doi: 10.1007/s00421-002-0652-y. [14] Corballis M. The Gestural Origins of Language. American Scientist (USA) [serial online]. 1999 [cited 2013 Dec 13]. Available from: http://www.americanscientist.org/issues/pub/1999/2/the-gestural-origins-of-language/5 [15] Iverson JM, Goldin-Meadow S. Why people gesture when they speak. Nature [Internet]. 1998 Nov 19 [cited 2013 Dec 13]; 398 (6708): 228. doi: 10.1038/24300.

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Cognitive Human

(Un)Enhancement? AUDREY LEE ‘16

Suppose it is 2040 and the technology to improve your ability to concentrate, think critically, and retain information is readily available. What do you do? In its most general form, human enhancement refers to “the use of medicine, technology, and techniques to improve the capacities of people beyond what we would consider normal or healthy” [1]. More specifically, drugs such as those used by college students to improve general mental faculties, including concentration, memory, and critical thinking, fall into a more discrete category known as cognitive human enhancement. Cognitive human

enhancement refers to “the amplification or extension of core capacities of the mind through improvement or augmentation of internal or external information processing systems” [2]. The development of cognitive human enhancers has become increasingly popular over the years, which can be illustrated primarily by the prevalent use of cognitive enhancement drugs, such as Ritalin and Adderall. These drugs increase academic productivity, by improving our ability to concentrate and think critically. According to recent surveys conducted across several college campuses, “as many as 20

percent of college students have used Ritalin or Adderall to study, write papers and take exams” [3]. Furthermore, as stated by research conducted by the National Institutes of Health, “almost 350,000 prescriptions for the alertness drug Modafinil are being written in the United States every year, even though the only condition for which it was approved until recently was narcolepsy, which affects only about 135,000 people” [4]. The large difference between the number of prescriptions being written for this cognitive enhancer and the number of people with the condition for which this drug is used to treat

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indicates that Modafinil is being used for reasons other than its intended purpose. The possibility of being able to take a drug to improve mental functioning is slowly becoming a reality, and as the prevalence and availability of cognition-enhancing drugs becomes more apparent, it is important to engage in the multifaceted ethical debate surrounding cognitive enhancement. How does a healthy human body respond to a drug meant to treat an illness? One facet of the complex debate surrounding the use of cognitive human enhancement is safety. By interfering with natural human capabilities, many side effects and unforeseen consequences may result, especially because cognitive enhancement involves altering a human’s ability to organize, think, or concentrate. According to a study conducted by the National Institutes of Health on cognition-enhancing drugs, these substances “may be accompanied by deleterious side effects, including toxicity and physical or psychological dependence” [4]. These risks can become amplified through the long-term use of the drug, which is usually necessary in order to achieve and sustain the desired enhancement effect. Further health risks associated with cognitive enhancers become apparent through the lack of safety data available surrounding the use of these drugs. While the Federal Food, Drug, and Cosmetic Act “requires manufacturers to show that drugs are safe for their intended purposes,” the act does not consider the health consequences that may result when a drug is used for a reason other than its intended purpose [4]. Even though cognitive

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Another aspect that must be considered is the social implications of using such drugs. In considering the social effects of taking cognitive enhancers, think about our competitive society. Consider the “limited places in prestigious schools or the high-stakes multitasking of modern work life” [5]. In this increasingly ambitious culture, “the freedom not to enhance may be difficult to maintain” [6]. Furthermore, it is important to note that “the more effective cognitive enhancements prove to be, the more pressure people will feel to use [these cognitive enhancements] to gain or retain socioeconomic advantages” [4]. Will the pressures to perform well and succeed in everyday society eventually coerce us towards the recreational use of cognitive human enhancers? Another potential societal consequence associated with the use of these drugs is the fear of a “cognitive arms-race” in which people might

“[spend] significant resources merely in order to keep up with the Joneses” [2]. If the recreational use of cognitive enhancers becomes common practice, members of society may find themselves expending an excessive amount of resources in search of the best enhancements. The use of such drugs may create a society in which those who do choose to cognitively enhance themselves begin to compete with others who are also cognitively enhanced, thus creating this cognitive arms-race. Further social implications involve socioeconomic status and the cost of using cognition-enhancing drugs. Because the cognitive-enhancing drugs for the sole purpose of enhancement, rather than the treatment of an illness, is viewed as a privilege, it is likely that those who are unable to afford these drugs will remain unenhanced, while those who are able to afford these same drugs will become enhanced. The cost of these enhancers creates a barrier that “could exacerbate the disadvantages already faced by people of low socioeconomic status in education and employment” [6]. By making these cognitive enhancers available to the public, there is “the possibility of increasing the “opportunity gap” between the rich and educated…and the poor and less educated” [8] as it becomes apparent that there are some who can afford such drugs, and those who are unable to. Through the use of these drugs and the resulting “opportunity gap,” the playing field for jobs and future careers becomes unleveled. This “opportunity gap” will only continue to increase through the amplified use of cognitive human enhancements, creating a further divide between differing socioeco-

As the prevalence and availability of cognitionenhancing drugs becomes more apparent, it is important to engage in the multifaceted ethical debate surrounding cognitive enhancement.

PHOTO Kaley Brauer ‘17

enhancers may have the ability to be beneficial to standard human cognition when taken in the absence of illness, there is still uncertainty surrounding the consequences of taking a drug to treat a condition that is not considered an illness. While all drugs and technologies have risks, “from a public health point of view, an acceptable ratio of risks to benefit is far different when people have a life-threatening illness as opposed to when [people] have milder symptoms or when they are well to begin with [5].” When drugs that are meant to treat illnesses are used to improve normal human cognitive capabilities, the health and safety risks associated with abusing these drugs become important concerns.

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STATISTICS Full-time college students, ages 18 to 22, are more than twice as likely as non-college students of the same age to use Adderall.

In 1991, there were 1 million prescriptions for Adderall and other stimulants; In 2010, there were 15 million prescriptions for Adderall and other stimulants.

nomic classes. Is it possible that a pill has the potential to create a society in which socioeconomic status plays such a large role in your future success? A third major aspect of cognitive enhancement stems from the authenticity of human ability. Some argue that the use of cognition enhancers reflects “our values and our sense of self” [6]. Part of this philosophical view considers self-improvement by improving natural human capabilities and then categorizing these enhancements as traits that can be bought or sold through the use of cognitive enhancements. This commodification of enhanced human traits, such as the improved ability to critically think, concentrate or remain alert, raises philosophical concerns surrounding the sale and purchase of unnatural human capabilities. Is it moral to purchase the ability to concentrate or memorize information in an attempt to exceed normal human cognitive

1 in 3 Adderall abusers are between the ages of 12 and 17.

function? The philosophical viewpoint on the use of the cognitive enhancements also explores the difference between one’s true self and one’s enhanced self. Are these enhanced traits acquired through the form of a pill less genuine than the natural capabilities given to us as humans? As cognitive enhancements become more and more prevalent and available, “…[people] fear that there will be a strong temptation to seek chemical magic bullets for solving problems better addressed by other means” [7]. The idea that the ability to critically think and memorize information, which was once achieved through hard work and persistence, can now be achieved through a pill undermines our natural capabilities. The philosophical reservations surrounding the use of cognition-enhancing drugs also extend beyond the tangibility of enhancement and examine the internal, personal debate that stems from a person’s use of cognitive enhancers.

References [1] University of Oxford. Human Enhancement [Internet]. 2013. Available from: http://www.fhi.ox.ac.uk/research/human_enhancement [2] Nick Bostrom. Cognitive Enhancement: Methods, Ethics, Regulatory Challenges [Internet]. 19 Jun 2009. Available from: http://www.nickbostrom.com/cognitive.pdf [3] The New York Times. The Adderall Advantage [Internet]. 2005 Jul 13. Available from: http://www.nytimes.com/2005/07/31/education/edlife/ jacobs31.html?pagewanted=all&_r=0 [4] Maxwell J Mehlman. Cognition-Enhancing Drugs [Internet]. 2004 Sep. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690227/

Common cognitive human enhancers, such as Adderall and Ritalin, have been used without a prescription by about 5% of U.S. college students.

Considering the authenticity of natural knowledge does “achieved excellence [have] a higher worth than talent that is bought?” [8]. Cognitive human enhancement and the ethical debate surrounding this topic can only be completely engaged by considering the various different approaches that make up the ethical debate. Through the distinct lenses of safety, social implication and philosophy, the question surrounding the use of cognition-enhancing drugs becomes far more complex. In order for members of society to fully understand the diverse aspects that have created this ongoing debate, the different facets of the debate and each of their contributing consequences must be clear. Say the time does come for you to consider making use of these cognition-enhancing drugs. Now what will you do?

EDITOR Hye In Sarah Lee [6] University of Pennsylvania Center for Neuroscience & Society. Cognitive Enhancement [Internet]. 2013. Available from: http://neuroethics.upenn. edu/index.php/penn-neuroethics-briefing/cognitive-enhancement [7] Allen Buchanan. Cognitive Enhancement and Education [Internet]. 2013. Available form: http://tre.sagepub.com.revproxy.brown.edu/ content/9/2/145.full.pdf+html [8] Nick Bostrom and Anders Sandberg. Cognitive Enhancement [Internet]. 19 Jun 2009. Available from: http://download.springer.com/static/pdf/814/ art%253A10.1007%252Fs11948-009-9142-5.pdf?auth66=1384457408_caeb31267a569d66ec98839865d8e9bd&ext=.pdf

[5] Steven E. Hyman. Cognitive Enhancement: Promises and Perils [Internet]. 24 Feb 2011. Available from: http://www.sciencedirect.com.revproxy. brown.edu/science/article/pii/S0896627311001097

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INTEGRATING INFORMATION IN EMR and Recent Breakthroughs in Health Information Technology KAVIA KHOSLA ‘16 Knowledge is power, and information undeniably fuels our society. Big data not only supports research and informs policymakers, but now it could be the solution to America’s healthcare woes. The last few years have brought to light important discussions about the future of healthcare in America. The Recovery Act of 2009, which created HITECH (Health IT for Economic and Clinical

Health Act), the Affordable Care Act of 2010, and recent breakthroughs and setbacks in the genetics industry make information in health one of the biggest priorities in the US. All these endeavors to reach accountable and efficient health care rely heavily on electronic health records (EHR). America’s healthcare system is ineffi-

cient and unsustainable; it is an irrefutable fact. Even now, the United States lags behind every developed nation in the quality of healthcare provided for the amount of money spent, which at this point is 17.7% of the US GDP. Genetics and personalized medicine have been noted as possible solutions. The goal of personalized medicine is to tailor care to each patient by using

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EHR eliminates errors in providing health care by making information more accessible, supporting clinicians in decision-making, and keeping an organized database for management of the quality of care.

genetic information to predict individual response to treatments rather than prescribing generic fixes to variable conditions. In turn, the US would significantly cut healthcare costs by participating in preventative and personalized care [11]. Given the prospects, there is not a proper infrastructure for this kind of care yet. Patients must participate in their care along with the doctor in order to harness the power of personalized medicine. Information besides genetic information, like extensive behavioral and medical history, must be documented and accessible to the patient’s health provider. In general, personalized care involves “participatory health care, patient involvement, or patient-centeredness” [12], all of which are not present in our health system at the moment but can be achieved through electronic health records. In this way, EHR is both a new system and an infrastructure for newer systems like personalized healthcare. Until the last three years, paper-based records prevailed in our health system. Information had a physical location, only accessible to a select few people involved in the care of the patient. In addition, paper based records are disorganized and portions are often misplaced. This negatively impacts the care of the patient, but also prevents the US from gathering all this data as “big data” to conduct research and track the

quality of care [1]. EHR eliminates errors in providing health care by making information more accessible, supporting clinicians in decision-making, and keeping an organized database for management of the quality of care. Studies since the 90’s have corroborated the enormous benefits of this method of health information exchange. The rate of patient readmission, medication and diagnosis errors, and duplicate testing decreases significantly in networks connected by an electronic health system [1]. A new wave of technology like EHR depends on three stages: infrastructure, software service companies, and the consumer applications that proceed. The advents of the electronic health record in the US emerged in the 1960’s, but it was almost wholly a private undertaking without proper infrastructure or help from the federal government [5]. Our health system produces mass amounts of information, and until recently no mass storage system existed that could conveniently and securely hold it. Until recently, cheap and convenient mass storage was not feasible. Since the last five years, however, even the average American citizen uses Amazon, Dropbox, and other cloud storage systems on a daily basis. According to Jeff Smith, co-founder of Prospect Health (November 2013), this cloud storage infrastructure is what

makes the EHR system a plausible endeavor. Software companies such as Epic realized the potential of this infrastructure and have become the leaders in electronic health software. This phase of the technology wave, though well on its way at the moment, must be carefully watched. As noted earlier, EHR was a largely private undertaking when it was first invented. This gave rise to the present situation, in which EHR systems advance within the context of private institutions and are unable to usefully exchange information amongst each other. This phenomenon, called interoperability, has been the largest hindrance to “meaningful use” of the EHR system. In 2009, HITECH set aside over 27 billion dollars to incentivize the widespread and meaningful adoption of EMR [4]. The goal of this law is to integrate and make accessible all the information that is put into the EHR systems. Only then can we ensure a cost effective process of emergency care, multi-provider care, and research. This is a momentous year in public policy and health technology, not only because of the Supreme Court ruling on genetic patenting, but also because Stage 2 of HITECH’s Meaningful Use will go into effect in 2014. Similar to the Supreme Court ruling, a key purpose of Stage 2 of HITECH’s Meaningful Use clause is to increase the flow of

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information in the American healthcare system. The goal in this case is to increase quality and accountability of care across the board. As stated earlier, the invention of EMR within the US was a private undertaking, and therefore encouraged fissured development of different EMR systems. Most health providers have their own unique EMR system, which ensures a lack of interoperability between the providers’ systems [7]. HITECH tackled this issue by making the “meaningful use” clause. The phrase “meaningful use” has become famous in the Health IT industry, as the clause within HITECH dictates the regulations under which a provider or health vendor must adopt an EMR system in order to get incentive money. Stage 1 of Meaningful Use engaged many more professionals with the EMR by offsetting the costs of implementing it. However, hospitals and physicians are not naturally inclined to share the information that they put on their EMR for multiple reasons (some doctors have reported hesitance in disclosing discharge reports for fear of insulting the patient) [9]. To address this, Stage 2 mandates that anyone receiving incentive money for their EMR system must have certain policies in place that make

the exchange of information with their patients and other providers efficient. For example, one stipulation reads, “Over 50% of requesting patients must receive electronic copy of their health information within 3 business days [of the request]” [9]. Meaningful use must be monitored carefully in order to complete the second phase of the EHR technology wave, formation of leading software companies that will pave the way for use of the technology. The last phase in the EHR wave is the production of applications that will work in the framework of this established software. As noted earlier, many advantages of the EHR system have been researched and systematically proven. Most of these benefits are seen, however, when a clinician or hospital interacts with the system rather than passively replacing the paper based records with an electronic one [1]. Lack of interaction is a major problem in transitioning to a completely electronic system. Numerous barriers in getting doctors to not only accept, but also interact with the EMR have made the transition from paper to EMR inefficient. Clinicians were, and often still are, hesitant to accept the new system from both

an economical perspective and out of convenience. For one, doctors are accustomed to physically handling all the notes about a patient in order to make a diagnosis or analyze their status. The lack of tangibility of the EMR often leads to a tendency to keep both paper and electronic records, actually increasing the amount of time that a doctor must put into records [2]. In order to record the progress of doctor’s visits, the physician would also have to type up notes during the visit, which makes the interaction feel less personal [2]. Lastly, most of the EMR systems in hospitals thus far have lacked free-text abilities. As Pam Khosla, MD (November 2013) explains, the EMR data entry process often looks like a flowchart of drop boxes, in which the physician must select binary answers to complex medical questions. Just in the past five to seven years, a significant number of technologies came out attempting to solve these problems. New software now includes speech to text features or programs that can translate free text progress notes into EMR reports [3, 4]. Nevertheless, there is little research to corroborate the advantages of these technologies, and some articles even concluded that they make no difference at all. In order to successfully implement the EHR system throughout

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The Obama administration has fronted nearly 30 billion dollars – 44,000 to 60,000 dollars per eligible health provider – to cover the costs of adopting EMR systems through HITECH health provider centers in America, private and public support must be provided to generate the proper applications. The Obama administration has fronted nearly 30 billion dollars – 44,000 to 60,000 dollars per eligible health provider – to cover the costs of adopting EMR systems through HITECH [4]. This has been a large step forward for EMR infrastructure, increasing the EMR use rate from 17% to 44% between 2008 and 2012 [5, 6]. The law requires that all health providers implement an

EMR system by the year 2016 or face penalties. Private investment has been historically low in healthcare information technology, but with the demand for electronic records and efficient healthcare tools, this trend is likely to shift [7]. Big data in healthcare is a tremendous gain for pharmaceutical companies, insurance companies, doctors, and other intersecting industries. Companies can use large amounts of patient information to model their products and services more effectively. Clinical decision support tools are being developed for doctors to guide their

REFERENCES

treatment practice based on large data sets. Doctors also look forward to live streaming of medical imaging such as echocardiograms and other emergency care imaging that would save time, money, and many lives. Given the endless possibilities of healthcare information technology at the moment, private investment is sure to reach these areas of the industry. When it does, we may finally see the beginnings of quality, accountable healthcare in the United States.

EDITOR Methma Udawatta

[1] Hersh W. The Electronic Medical Record: Promises and Problems. J Am Soc Inf Sci. 1995 [cited 2013 Nov 20];46(10):772-776. Available from: http://skynet.ohsu.edu/~hersh/jasis-95-emr.pdf

[7] The IBM Center for the Business of Government. Dr. Farzad Mostashari on Nationwide Interoperability [Online video]. 2013 Sep 13 [cited 2013 Nov 20]. Available from: http://www.youtube.com/watch?v=Qxz04PQzVWk

[2] 2Makoul, G, Curry R, Tang P. The Use of Electronic Medical Records. J Am Med Inform Assoc. 2001 [cited 2013 Nov 20];8(6):610-615. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC130071/#__ffn_sectitle

[8] Blumer T. Politico’s Purdum: Obama Had to Lie to Pass ACA because the Public Couldn’t Handle ‘Unpleasant Truths’. 2013 Nov 17 [cited 2013 Nov 20]. In: Blumer T. NewsBusters [Internet]. Available from: http://newsbusters.org/blogs/tom-blumer/2013/11/17/politicos-purdumobama-had-lie-pass-aca-because-public-couldnt-handle-un

[3] Johnson S, Bakken, S, Dine D, Sookyung H, Mendonca E, Morrision F, Bright T, Vleck T, Wrenn J, Stetson P. An Electronic Health Record Based on Structured Narrative. J am Med Inform Assoc. 2008 [cited 2013 Nov 20];15:54-64. Doi: 10.1197/jamia.M2131 [4] Shea S, Hripcsak G. Accelerating the Use of Electronic Health Records in Physician Practices. N Engl J Med. 2010 Jan 21 [cited 2013 Nov 20];362:192-195. Doi: 10.1056/NEJMp0919140 [5] Lohr S. The ‘Miracle’ of Digital Health Records, 50 Years Ago. 2012 17 Feb [cite 2013 Nov 20]. In: Loh S. The New York Times: Bits [Internet]. Available from: http://bits.blogs.nytimes.com/2012/02/17/the-miracleof-digital-health-records-50-years-ago/?_r=2 [6] Hospitals, Physicians Make Major Strides in Electronic Health Record Adoption [Internet]. Robert Wood Johnson Foundation. 2013 July 8. [cited 2013 Nov 20]. Available from: http://www.rwjf.org/en/about-rwjf/ newsroom/newsroom-content/2013/07/hospitals--physicians-makemajor-strides-in-electronic-health-re.html

[9] Levins, H. Video Excerpt: Farzad Mostashari’s Talk at LDI Health Policy Seminar [Internet video]. 2013 Sep 15 [cited 2013 Nov 20]. Available from: http://ldi.upenn.edu/about/news/2013/09/14/video-excerpt-farzad-mostashari-s-talk-at-ldi-health-policy-seminar [10] Centers for Medicare & Medicaid Services. Stage 2 [Internet]. [Updated 2013 Nov 07; cited 2013 Nov 20]. Available from: http://www.cms. gov/ Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Stage_2.html [11] Kmiecik T, Sanders D. Integration of Genetic and Familial Data into Electronic Medical Records and Healthcare Processes. Northwestern University. 2009 Feb 02 [cited 2013 Nov 20]. Available from: http:// www.surgery.northwestern.edu/ docs/KmiecikSandersArticle.pdf [12] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428816/ soon ill be a very old man and very old men dream of summer

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Beyond The Consent Form:

WHAT WE SHOULDN’T MISS FROM THE SUPPORT CONTROVERSY SOPHIA (SEON YEONG) PARK ‘14

The letter filed by the Federal Office for Human Research Protections (OHRP) against the Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT) presented in March 2013 has been the most contentious issue in the neonatal research community in 2013 [1]. Yet, the case somewhat passively closed when OHRP withdrew its proposed sanction in June of the same year [2, 3]. OHRP initially accused the SUPPORT investigators and affiliated institutions for their failure to fully inform the study’s risk to parents of enrolled subjects during the consent process, but with its pullback, charges against the SUPPORT researchers and ethics committees that approved the consent form were lifted and no further action

were to be taken for the time being. However, even though OHRP withdrew, a controversy remained unresolved. Rather, continued disputes in the bioethics community exposed key limitations of the current system that must not be silenced or overlooked, such as a need for reassessment International Review Board (IRB) standard with consideration of possible conflicts of interest (COI) and establishment of standardized verbal consent process that can ensure a thorough communication between investigators and patients. The SUPPORT was a nation-wide NIH-funded randomized clinical trial conducted from 2005 to 2009 at twenty-three U.S. hospitals, enrolling

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of 1314 premature babies [4]. The study aimed to determine an optimal level of oxygen treatment for premature infants. In their preterm, infants do not have a fully-developed respiratory system and requires an external oxygen supply. While oxygen supply may help infants continue to develop, high level of oxygen may lead to excess growth of retinal blood vessel and cause blindness, a symptom known as retinopathy of prematurity (ROP). In order to find an optimal oxygen concentration that can minimize predicted eye damage and maximize survival rate, the study randomly assigned enrolled infants into one of the two treatment groups of higher oxygen level (91-95%) and lower oxygen level (85-89%), both level ranging within the standard of care (85-95%) [4].

gen treatments were unknown, and that was precisely what the SUPPORT study aimed to illuminate. At the current stage, doctors at Neonatal Intensive Care Units (NICU) are prescribing the treatment based on the uncertainty. The SUPPORT study intended to improve such limitation in current understanding and to establish a reliable, evidence-based clinical treatment. The result of the study was clearly fruitful, and will help improve the quality of medical care and save many premature babies’ lives at NICU in the future. However, at the time when the study was being implemented, the researchers’ and physicians’ understanding of the outcomes of either range of oxygen supply was limited, and therefore, it had been impossible to warn patients about the risk.

OHRP letter criticized the SUPPORT study consent form for failing to fully identify potential risk involved in the research. According to the OHRP investigation, majority of the SUPPROT study consent forms did not note that the higher oxygen group had a greater chance to develop ROP and lower level involved higher mortality. Death was not mentioned as a risk in any of the forms, although it was perceived as a possible outcome by many investigators. Instead, the forms assured that there is “no predictable increase in risk” expected by the enrollment of the study [1].

In response, con-SUPPORT bioethicists Alice Dreger, a bioethics professor at the Northwestern University, pointed out that considering that the aim of clinical treatment was not to cure, but to find the difference between two groups [6]. At least, the hypothesis was expecting that one group would receive more damage compared to the other group. If one group were anticipated to be less benefited, the possible side effect must have been addressed. The side effects that an inadequate oxygen treatment would generate, such as ROP, higher mortality and neurodevelopmental impairments, were known at the beginning of the study, but were not mentioned in the consent forms. However, these side effects should have been stated, as it is logically predictable that a less benefited group would be affected by those.

SUPPORT researchers and NIH officials defended against the OHRP letter, asserting that: (1) the associated risk, such as higher possibility of ROP for higher oxygen group and higher mortality for lower oxygen group, was not known at the beginning of the study, and (2) the risk involved in the study is also risk perceived by standard of care, and there was no ‘additional’ risk of the research treatment [5]. The first main point of the defense is that, in the beginning of the study, consequences of either range of oxy-

Also, SUPPORT critics claim that by assigning premature infants into either of the treatment groups, investigators were limiting what those babies may receive, and therefore it does involve an additional risk [7, 8]. If the babies had not been enrolled in the study, they would have been treated with physician’s discretion depending on

their condition, receiving an oxygen supply ranging anywhere in 85-95%. However, if they are enrolled in the study, their treatment is more strictly restricted into either higher or lower range, and their individual conditions would not be considered to adjust the treatment level. Yet, it should be also considered that there remains a room for dispute regarding whether physicians’ discretion would necessarily be beneficial, as those would be a guessbased treatments in essence, not an evidence-based ones fully confirmed by RCT. The second defense point put forth is that the consent forms do not contain any flaw, as both higher and lower oxygen treatment groups correspond to the oxygen supply range approved in the current standard of care, and any side effects expected by the study treatment may also be resulted by the very process of the standard of care. David Magnus, a bioethicist at Stanford University, argued that such side effects can be defined as a “minimal risk,” and it is not unethical that the consent forms did not fully specify each of the risks [9]. On the other hand, con-SUPPORT bioethicists take a different stance regarding the minimal risks [1]. They argue that risks such as death and blindness would be too severe to be simply unacknowledged. By not addressing such risks, investigators would not be fully informing patients of the risk as comprehensively as they claim. While explanation provided by SUPPORT defenders is logical, there is a room for disagreement about whether serious illnesses such as blindness and death could be allowed to be unmentioned to the parents of enrolled infants. The repeated rounds of criticism between SUPPORT critics and defenders have clearly revealed conflicting perspectives of each side. Each side put forth its own interpretation and logics with conflicts of interests (COI). In

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August 2013, HHS public hearing was organized with an aim to address unresolved doubt and to provide opportunity to communicate difference between two sides, and both side had chance to explicate themselves [10]. However, it hardly seemed they reached a negotiation point, with many of arguments being elaborate reiterations of above points. This undue tension created by continued disputes is to be resolved, and the focus should be on how to supplement the drawbacks of the current system exposed by this controversy, as trying to define whether and who to penalize would only result in further polarization of the bioethical community. The first point to consider is a possible need for verbal communication or education process stipulation. During the HHS public hearing, Sharissa Cook, a mother of one enrolled infant, stated that she was not fully informed about the study when she gave her consent [10]. “Had I known the full extent of the study, I would not have given my consent,” Cook recalled. She added that the investigators compensated her ability to make an informed decision by being “not forthcoming with the information,” and argued that the information should be presented so that a person of any education level can understand. She also criticized that the title gave a false impression, stating

that the name of the study, SUPPORT, is “an inducement to participate”. While it is unlikely that the SUPPORT investigator intentionally misguided parents of infants, Cook’s experience highlights potential communication error during the consent process resulting in consenters’ misunderstanding, which could imply a fundamental problem of the current consent process. Numerous studies had already frequently addressed limitation in the consent procedure [11, 12, 13]. Oftentimes, patients have a poor retention of information that they received during the consent procedure [11]. It is also a probable that the patients are intimidated by a long list of protocol and simply rely on experts’ description, and signing the consent form as “a matter of ticking boxes” [13]. The reason for this would be far from individual investigator’s moral failure. With the time and resource constraints faced, the consent process at the current stage is inevitably liable to human error. As the complex protocol is passed down, verbal education during the consent process could be abridged at individual investigator’s discretion, while brochures written in professional languages are incomprehensible to laypeople. It would be unreasonable and impossible to seek consent for

every detail, but bias that could be introduced when choosing details to actually tell during the limited time may introduce conflicts. In order to prevent possible miscommunication during the consent process, the ways to effectively inform patients from varied background should be accommodated. A research by Shukla et al (2012) found out that a visual aid (DVD) and lower reading grade level brochure helped greatly to patients’ understanding, so such could be recommended to be prepared at the beginning of the study [12]. To accommodate patients with different levels of interests, materials of varying degrees of specificity could also be prepared. Dr. Onora O’Neill, a professor at Newnham College, UK, suggested that amount and level of information given to be dictated by patients, not physician. It would help reduce misunderstandings if the consent forms are examined by a group of non-medical professions before getting approved. Evidently, such solutions will involve more spending, and could be compromised when considered realistically. Cost-benefit consideration needs to be weighed in. However, if applied appropriately, constructing guideline on materials and building available information bank would serve as an effective means of communication to build

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trust between patients and researchers. Second, IRB standard may need to be reestablished. The concern of many SUPPORT critics was that none of the 23 institutions raised questions to this controversial, if not flawed, consent form. This also takes us back to the criticisms that have been previously addressed: the current IRB policies and procedures are somewhat lax and allows a room for biases. According to the study by Vogeli et al., in an anonymous survey of 296 IRB chairs, onethird responded that their policy did not require voting members to disclose industry relationship, and one-fourth answered that they did not defined a course of action in case IRB member with COI is acknowledged [14]. Although the possible COI has seldom been covered in the SUPPORT discussion, it is obvious that it could have

been present at both institutional and individual levels. In order to improve the clarity of voting process and promote self-awareness among IRB members, clearer guideline for COI standard in IRB should be accommodated. While repeated claim and dispute may oblige temporal delay and additional spending, protecting the rights of study subjects should always be a prior issue. Drawbacks exposed by the SUPPORT dispute should not be overlooked or silenced, as it will clearly bear a larger implication in both medical research and bioethics community. Considering this is a nation-wide study supported by a national agency with major media attention, it will serve as an important precedent and may affect numerous other smaller-scaled research studies. The obvious flaws of the consent process exposed at the current state must

REFERENCES [1] Public Citizen. The Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT) – Analysis of the Complete Protocol and Complete Consent Form [Internet]. 2013 [cited Dec 18 2013]. Available from: http://www.citizen.org/documents/2124.pdf [2] Public Citizen. Human Research Protections under Federalwide Assurance (FW A) 5960 [Internet]. June 4 2013 [cited Dec 29 2013]. Available from: http://www.citizen.org/documents/2111_ohrp_retraction_support_4_2013.pdf [3] U.S. Patient Protection Agency Drops Plan to Sanction Leaders of Infant Study [Internet]. Science Mag. June 6 2013 [Cited Dec 28 2013]. Available from: http://news.sciencemag.org/people-events/2013/06/u.s.patient-protection-agency-drops-plan-sanction-leaders-infant-study [4] SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Target Ranges of Oxygen Saturation in Extremely Preterm Infants [Internet]. NEMJ. Available from: http://www.nejm. org/doi/full/10.1056/NEJMoa0911781 [5] Drazen JM, Solomon CG, Greene MF. Informed Consent and Support [Internet]. NEJM. May 16 2013 [cited Dec 30 2013]. Available from: http://www.nejm.org/doi/full/10.1056/NEJMe1304996 [6] Dreger AD. FAQ on the SUPPORT study controversy [Internet]. [cited Dec 29 2013]. Availabel from: http://www.alicedreger.com/support.html [7] Subject to question [Internet]. Nature. 21 August 2013 [cited Dec 27 2013]. Available from: http://www.nature.com/news/subject-to-question-1.13573

be addressed to identify the cause and to productively discuss possible preventions. It is hopeful that Kathy Hudson, the deputy director of NIH who initially fully endorsed the NIH-funded SUPPORT study, offered to award grant supplements to investigate this case [10]. With NIH support, it would be possible to reexamine and evaluate strengths and weaknesses of current system and research process. Although the specifics of NIH inspection is not yet determined, the grants should aim to create a productive outcome, such as readjusting IRB regulation standard, clarifying COI standard, and creating a realistic verbal consent process specification if necessary. At the very least, the focus should be on diagnosing systemic flaws, not emphasizing on individual moral defects or punishment.

EDITOR Russell Shelp [8] Hoffman J. Watchdog Halts Action on Researchers [internet]. June 5 2013 [Cited Dec 28 2013]. Available from: http://www.nytimes.com/2013/06/06/ health/watchdog-halts-action-on-researchers.html?_r=0 [9] Magnus D, Caplan AL. Risk, Consent and SUPPORT [Internet]. NEJM. May 16 2013 [cited Dec 29 2013]. Available from: http://www.nejm. org/doi/full/10.1056/NEJMp1305086 [10] United States Department of Health and Human Services. Matters Related to Protection of Human Subjects and Research Considering Standard of Care Interventions [Internet]. 2013 [cited Jan 2 2014]. Available from: http://www.hhs.gov/ohrp/newsroom/rfc/Public%20 Meeting%20August%2028%202013/supportmeetingtranscriptfinal.pdf [11] Sahin N, Oztürk A, Ozkan Y, Demirhan Erdemir A. What do patients recall from informed consent given before orthopedic surgery? Acta Orthop Traumatol Turc. 2010;44(6):469-75. [12] Shukla AN, Daly MK, Legutko P. Informed consent for cataract surgery: patient understanding of verbal, written, and videotaped information. J Cataract Refract Surg. 2012 Jan;38(1):80-4. [13] O’Neill O. Some limits of informed consent. J Med Ethics. 2003 Feb;29(1):4-7. [14] Vogeli C, Koski G, Campbell EG. Policies and management of conflicts of interest within medical research institutional review boards: results of a national study. Acad Med. 2009 Apr;84(4):488-94.

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ARTWORK Kaley Brauer ‘17 Mary O’Connor ‘16

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A NEW AGE OF

DECEPTION: How Technology is Changing the Face of Lying SHANNON MCCARTHY ‘15.5

Our words used to vanish. Before Blackberry and Facebook, social interactions floated away nearly as fast as they appeared, leaving only a memory. As Cornell researcher Jeff Hancock explained in his TED talk, “The Future of Lying,” humans have evolved to interact without a record because there never was one [1]. However, relatively new text based technology, including text, instant message, and Twitter now put our daily interactions into writing, into a record. Our conversations stack neatly in email inboxes and Facebook feeds, ready to be searched and verified at any time.

Technology’s record of our conversations is just one of the many ways technology is changing the way we interact and subsequently the way we lie. Technology has changed every corner of our interactions, from finding a date to finding a job, from emailing a college to texting a friend. Subsequently, the medium and dynamics of our interactions have altered, so our lies must also change.

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MAINTAINING FRIENDSHIPS Technology has changed the way friends interact. Text messaging, phone calls, Facebook, Snapchat and a host of other technological innovations make us constantly accessible to our friends [2]. We can be contacted almost anytime and anywhere. Therefore, in order to maintain our friendships, while maintaining a shred of privacy, people have started using what is now termed the “butler lie” [2]. Butler lies are lies meant to preserve the relationship with a friend that initiated unwanted social interaction by calling at a horribly inconvenient time [2]. Butler lies are employed to avoid a new conversation, smoothly end an existing conversation or belatedly explain an instance of bad communication [2]. For instance, a Facebook chat conversation with a good friend is dragging on and you are unbelievably bored. You do not want to offend your good friend, so you may say “Oh, sorry, I’ve got to go, the boss is coming”. This lie gracefully ends an unwanted conversation without damaging the friendship.

Therefore, these lies act as technological butlers, buffering us from the outside world, just like the servants for whom they were named [2].

avoid conversation, while preserving a friendship [2]. Therefore, the butler lie grants us an excuse for inaccessibility, while maintaining our friendships [2].

Further, butler lie have arisen from our constant accessibility and are enabled by the ambiguity of technology [2]. Using bad cell reception or a dead phone battery as an excuse for not answering someone only works when there is ambiguity in the interaction [2]. That is, using the “I left my phone at home” excuse would not work if the other person knew that their text message had been opened.

Given this positive function of the butler lie, Hancock advises against ambiguity reducing features of technology, such as the Facebook “seen by” feature or the blanket availability status in most instant messaging interfaces [2]. Hancock instead proposes features that would better facilitate selectively ending conversations, such as an IM availability status that can be personalized for different people online, a feature that has actually been implemented by Facebook after the release of Hancock’s paper [2].

While deception usually triggers a host of negative emotions, Jeff Hancock, the researcher who coined the term “butler lie”, actually claims that these lies can be a positive force [2]. He reasons that technology within our friendly social interactions, is meant to foster relationships [2]. Butler lies work toward this same goal [2]. Most people only lie with motive, and the motive of the butler lie is to gracefully and delicately

Ultimately, the Butler lie can be considered a positive form of lying. While it’s never particularly good to lie, the Butler lie protects both our friendships and our privacy. Therefore, while technology may be spurring us to lie, these lies are not necessarily bad.

GETTING A JOB Aside from managing friendships, technology has transformed other ordinary activities, including getting a job. Job-hunting has moved to the internet with websites like CareerBuilder, Monster, and LinkedIn, a social networking site for professionals, largely replacing the traditional paper and ink resumes of ten years ago. Just like technology changed the way we lie to friends, so has it changed the way we lie while job-hunting. The motivation for lying while job-hunting, whether in paper or online, is the same; applicants want to appear as qualified as possible, but also need to present themselves as honest, since nobody wants to hire a liar [3]. The primary difference between tradi36

tional resumes and online resumes is the number of people that can access them [3]. Almost anyone with internet access can view a public LinkedIn profile, while only select people chosen by the applicant get to see a traditional printed resume [3]. More potential viewers means a higher possibility of being caught in a verifiable lie, such as exaggerating responsibilities from a previous job [3]. This increased chance of being caught decreases the motivation to tell verifiable lies [3]. As a result, LinkedIn resumes are more truthful in areas important to employers, including prior work responsibilities, but contain more lies concerning other, non-verifiable aspects of the application, such as the applicant’s hob-

bies outside of work [3]. Conversely, traditional resumes had more deception related to their responsibilities, but less deception in their interests [3]. For example, an applicant with a public LinkedIn profile may not list extra responsibilities under her previous employment section, but may say she reads the New York Times every morning instead of the reality in which she rolls out of bed with just enough time to get to work. Conversely, a traditional applicant is more likely to lie about his previous jobs, which fulfills his need to self-enhance and makes him less likely to embellish his hobbies. Both these lies make the resume more appealing and account for the chance of being caught in a lie [3]. Thus, the

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public aspect of LinkedIn profiles, enabled by technology, alters the type, but not necessarily the frequency of lies [3]. This finding can be considered a victory for technology. By increasing the

exposure of our resumes, LinkedIn has effectively decreased the amount of deception in areas that are more important to employers, making applicants more honest where it counts. Presumably, if applicants are more honest in their applications in the areas that mat-

ter, then the more qualified applicants will get the jobs they deserve instead of being beaten by applicants who edged them out with exaggerations. Subsequently, while technology has changed the way we lie to our employers, this change may very well be for the better.

by of an independent judge and finally an accuracy score given by a person trained to code for accuracy [4]. This study suggested that women lie more than men with their profile pictures [4]. They further demonstrated that womenâ&#x20AC;&#x2122;s profile pictures often misrepresent them by showing pictures of themselves with significantly better hair or skin tone or even older pictures in which they look noticeably younger [4]. Like with text, misrepresentation

seems to be frequent. However, photo misrepresentation differs in that it is not particularly subtle [4].

GETTING A DATE Technology has also changed the way people meet and date, as is evident in the long and dizzying list of online dating sites available. By changing the medium of meeting romantic partners, technology has also affected the way we lie in dating. Prospective daters face the same challenge as online job applicants. They want to enhance themselves and appear attractive, yet they also want to appear authentic and honest [4]. Balancing these two motives affects their lying [4]. Unsurprisingly, recent studies have found that online daters lie in both the text and photos of their profiles [4, 5]. Two studies have recently been released on online dating lies.

Further, these more overt photograph lies activate a process called equivocation that relieves the internal tension between self-enhancement and authenticity in photographs that usually prevents people from lying [4]. For example, when a women posts a picture of herself in which she looks better than

The first study focused on the accuracy of the text portion of profiles [5]. In this study, researchers had online daters rank how accurate their profiles were, and then the researchers collected physical measurements to verify the profiles [4, 5]. The study demonstrated that lying in the text portion of profiles is frequent, but subtle [4, 5]. Therefore, while a 5â&#x20AC;&#x2122;10â&#x20AC;? accountant may not have claim to be an astronaut, he may have say that he is 6 feet tall. Therefore, daters balance their lies in text by making them frequently, but subtly, so as to increase attractiveness without deterring from authenticity [4, 5]. In the second study, a team of researchers, led by Jeffery Hancock and Catalina Toma focused on lies within profile pictures. They ranked the accuracy of a small pool of online dating profile pictures using first a self-reported accuracy, second an accuracy ranking given SPRING 2015 || THE TRIPLE HELIX

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she normally does, she doesn’t necessarily feel that she is being unauthentic because she is able to justify the picture as real in the sense that the picture may look like her on a special occasion [4]. Equivocation, therefore, reduces the bad feeling of lying because the liar is able to convince herself that her wildly inaccurate picture looks like herself sometimes. This in turn makes it easier for her to misrepresent herself in her profile picture [4]. Overall, lies were found to be frequent in both text and pictures, which suggests at least some preference for self-enhancement at the risk of losing authenticity [4, 6]. This trend aligns with “the hyperpersonal model’s concept of selective self-presentation” [5, 6]. This hyperpersonal model, originally proposed by Joseph Walter in 1996 outlines that online interactions encourage selective self-presentation, or the favorable presentation of

yourself, because the medium is slow and highly editable [5, 6]. However, the hyperpersonal model also suggests that the communication through technology also discourages selective self-presentation because lying could jeopardize future face-to-face interactions [5, 6]. By applying this model to online dating, daters are encouraged to deceive in their profiles to enhance their self-presentation to get a date, but are tempered by the reality that their lies could negatively impact the relationships they are starting [5]. Selective self-presentation, the careful and strategic presentation of oneself, exists in online dating within both textual interactions and profile pictures perhaps because the highly editable nature of online dating sites compared to meeting people through other means [4]. While technology did not create selective self-presentation, it has provided a greater opportunity to give into the impulse to self-embellish [6]. Within dating, the need to present oneself as attractive, yet honest may always have been there, and online interactions have only made the urge to submit to selective self-presentation greater by making it easier to do. Within dating, this new deceit has the potential to be disastrous because there are no positive ramifications as with online applications and the Butler Lie. Further, finding a romantic partner is significantly more important than finding a job, which makes these misrepresentations all the more dangerous. It is one thing when a lie lands you a bad job, it

REFERENCES [1] “Jeff Hancock: 3 types of (digital) lies.“ TEDTalks. Youtube Video. http://www. youtube.com/watch?v=nn5k4snG3rA [2] Hancock J, Birnholtz J, Bazarova N, Guillory J, Perlin J, Amos B. Butler Lies: Awareness, Deception and Design. CHI 2009;517-526.

is an entirely different matter when a lies lands you a bad spouse. Technology has shaped the way we deceive one another in both a positive and a negative way. We now use butler lies to preserve friendships and our privacy. We are honest about our responsibilities and a little more deceitful about our interests to appear more qualified to potential employers, which is a positive shift in our lying habits. Finally, we lie to possible romantic partners both in text and in our photographs to present ourselves in the best possible light, a change that seems dangerous and frightening. Further, the striking aspect of these changes imposed by technology is that our motives have remained stable. Before computers, tablets and blackberries, people still wanted to keep friends, get a job and meet their dream guy or girl. Technology has only changed the rules of the game. It has made us nearly constantly accessible to our friends, which requires mild deception to preserve both our friendships and our privacy. It has threatened our old, more vulnerable lies about responsibilities in traditional resumes and forced us to selectively self-present in more unverifiable ways. And it has slowed down dating initiations from actual conversations to virtual profiles, which gives daters more opportunity to manipulate how they present themselves. In the end, we still strive for the friends, the jobs, and the dates, and only the course has changed.

EDITOR Hank Baker [3] Guillory J, Hancock JT. The Effect of Linkedin on Deception in Resumes. CyberPsychology, Behavior and Social Networking 2012; 15 (3); 135-140. [4] Hancock JT, Toma CL. Putting Your Best Face Forward: The Accuracy of Online Dating Photographs. Journal of Communication 2009; 59; 367-386. [5] Toma CL, Hancock JT, Ellison NB. Separating Fact from Fiction: An Examination of Deceptive Self-Presentation in Online Dating Profiles. Personality and Social Psychology Bulletin 2008; 34 (?); 1023-1036. [6] Walther JB. Computer-mediated communication: Impersonal, interpersonal and hyperpersonal interaction. Communication Research 1996; 23; 3-44.

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Natural

Worm Control

THE POTENTIAL USE OF MEDICINAL PLANTS IN SYSTEMS FOR THE CONTROL OF WORMS IN RUMINANTS MIRANDA NORLIN â&#x20AC;&#x2DC;17

WHATâ&#x20AC;&#x2122;S WRONG WITH CURRENT SOLUTIONS? The infestation of livestock with intestinal parasites is a leading cause of poor productivity and economic loss worldwide [1, 2, 3]. Whether production is limited by death of the animal, loss of weight, or decreased production of milk or fiber, these worms are bad for the animal and for the farmer who needs to profit from it. The predominant method of control and elimination of these parasites is the administration of chemical formulas, or anthelmintics, which kill the parasites and leave the host, at least in theory, free of worms. The exclusive use of these

drugs is, however, rapidly becoming ineffective and unsustainable and so worms are a growing problem, especially for farmers raising sheep, goats, and other small ruminants in the developing world. Cost, availability, and environmental impact are three issues that make continued use of conventional anthelmintics untenable. These drugs are already prohibitively expensive for most farmers in developing nations. To compound this, most modern formulas are oil-derived compounds. As oil-reserves are depleted world-wide, the availability of oil-derived compounds is bound to decrease and their

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price to go up [4]. Even today it is very difficult for many small-scale, rural farmers to obtain conventional chemical anthelmintics. In Pakistan, for instance, many farmers cannot afford these drugs or are sold substances that have been diluted to a subtherapeutic (ineffective) level [5]. Because the price of proper treatment is often greater than the animal’s worth, farmers will often dilute the drug or not complete the full course of treatment [5, 6, 7]. Not only is this course of action ineffective

in the short term, but it also aggravates the issue of the worms’ growing resistance to these drugs. The rapidly decreasing efficacy of anthelmintics is approaching a point of crisis. Resistance, the decreased response in a parasite population to a drug that is normally effective, cannot be reversed [8], and is inherited [2]. Many scientists are focusing on finding replacements for now ineffective drugs and strategies to avoid the evolution of

resistant worms in the first place. Although it is possible to reduce the rate at which worms become resistant, the efficacy of the drugs currently used will only continue to decrease. In the face of synthetic anthelmintics’ rising cost, environmental impact, and declining ability to control worms, researchers, veterinarians and farmers are investing more effort in determining the potential of medicinal plants to help control these parasites [ 3, 6, 7, 9].

WHY MEDICINAL PLANTS? Medicinal plants have been used in traditional medicine around the world for centuries, but only recently has there been significant interest in their scientific validation. As synthetic dewormers become less effective and organic and sustainable farming practices become more popular, the identification of medicinal plants that are effective anthelmintics is increasingly important [10]. Medicinal plants make more environmentally friendly drugs than the petrochemicals that are commonly used, and sustainable growth, harvesting, and processing of such plants could provide a cheap and local source of medication. The use of some plants, like the legume Lespedeza cuneata, is made even simpler because it has been found to be effective when provided as forage or dried in hay [11, 12, 13]. Some challenges, however, remain: most plants are not available year round; some of the formulations traditionally

used are difficult to prepare; there are gaps in our knowledge about their efficacy, safety margins, and side effects; and standardization is often very difficult to achieve [5]. Yet their study is worthwhile. Much of the hesitation to use medicinal plants stems more from the current lack of knowledge [7] than from doubts about their intrinsic therapeutic worth. By establishing what plants are valid treatments, how they are best administered, in what doses they should be used, and what potential side-effects or toxicity may be associated with them, researchers would provide a usable therapeutic tool that can be incorporated with conventional dewormers, pasture rotation protocols, antiparasitic vaccines and proper nutrition to create comprehensive parasite managements systems [6, 7, 8].

IDENTIFYING AND VALIDATING MEDICINAL PLANTS The preliminary step to any research is, of course, to identify plants of interest. Fortunately centuries of trial and error have established, in the form of traditional botanical knowledge, a body of information that can guide researchers towards species that contain anthelmintic active compounds. Surveys and conversations with indigenous tribes and ‘old timers’ can furnish research-

ers with a starting group of plants that can be narrowed by comparison to previously tested plants before research is carried out. The results of such surveys and screening can be applied broadly, but it is important, when assessing the worth of

FAMACHA ANAEMIA GUIDE This guide indicates how to identify ruminants that have been infested with Haemonchus contortus, a parasite that mainly affects their hosts by sucking blood and causing anemia and other blood loss related symptoms. By looking at the ocular mucus membranes of the animals, infection can be easily identified.

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medicinal plants as a long-term solution, that such evaluation is made on a more local basis. Medicinal plants will be cheaper and more sustainable than petrochemicals, but only if the plants can be grown relatively locally and are a hardy species. One study in the Netherlands, for example, investigated the anthelmintic action of a papaya seed extract. The results were limited but even had the extract been effective it couldn’t have been a viable solution for Dutch farmers as the price of import would be prohibitive [4]. Rather, efforts should have been focused on searching for a plant that grows, or can easily be grown, locally. A good illustration of such a search might be found in a case study of my family’s property in the mountains of Western North Carolina. Several years ago I chopped down a large number of Ailanthus Altissima in an attempt to clear part of a pasture for hay. This is a fast-growing, tree with a pungent smell that is invasive in WNC [14]. A strong smell indicates that a plant has a high concentration of aromatic secondary compounds, chemicals which frequently possess insecticidal or medicinal qualities, so I looked it up again when searching for plants that might have anthelmintic compounds [3]. A. altissima is indeed commonly stripped

of its bark, along with others in the genus Ailanthus, for use as an anthelmintic in Indian traditional medicine [15, 16]. The potential of plants that are already invasive in an area should be especially noted as their use for medicine would turn a liability into an asset. Once a plant has been identified, research, on worms in an incubated dish or (in vitro), should be done to cheaply and efficiently screen for anthelmintic activity [1], or, in cases like this where such activity has already been documented, to investigate the best way to administer the secondary compounds and most effectively extract them. The best method will depend on the relative bioavailability, compound stability, safety, and cost of production of each method of administration [17]. In some cases, this method may be involve less processing if directly feeding the plant in question is medicinally effective. Research on worm infested livestock (in vivo) should be carried out to determine whether feeding whole plant parts controls worms and to determine the appropriate dose, dosing protocol, and safety margins of the treatment in whatever species of animals are of interest. Ailanthus excelsa, a close relative of A. altissima, is listed in a review of potential antifertility agents [18], so special attention should be paid to the

safety, or rather, risks, associated with A. altissima’s use in breeding stock. Plants that show anthelmintic potential should also be compared to others in the same area that might be effective. Ailanthus shows good potential as an option for anthelmintic treatment in North Carolina and some other states. Elsewhere however there might be other equally or more viable options. In Texas, for instance, Melia azedarach is also classified as invasive [19]. This plant is also originally indigenous to India and studies have found that its leaves and seeds contain anthelmintic compounds [19, 20, 12]. Where anthelmintic compounds are most concentrated in the two plants is significant. In places where both plants are invasive, M. azedarach would be the better choice as leaves and seeds can be more sustainably harvested than bark, whose careless or frequent harvesting can result in the death of the tree [7]. Although in the case of invasive plants this issue is less significant, (farmers might, in fact, be eager to reduce the population of the invasive species) the location of secondary compounds is important, especially if the plant concerned is slow growing, as it is unwise to wipe out the plant from which one is obtaining medicine.

PLANT PREPARATION AND COMPOUND EXTRACTION Methods of plant preparation to obtain a usable medication vary in ease, costliness and effectiveness and are also relevant to our choice of plant [7]. Some secondary compounds may need to be extracted and administered dissolved in a solvent. The active secondary compounds in M. azedarach offer a good example of the variance in how different solvents work to extract them and facilitate their action. Maciel et. al. tested extracts of M. azedarach leaves and seeds using hexane and ethanol, and chloroform and ethanol respectively. For both leaves and seeds the LC50, or concentration necessary to kill half of the worm population treated, of the

ethanol extracts was significantly lower in almost all cases than the LC50 of the hexane and chloroform extracts [19]. For this case, and for these secondary compounds, ethanol is the better solvent. A study by Eguale et. al. investigating the potential anthelmintic activity of Coriandrum sativum offers an explanation of the varying effectiveness that might be applicable. When testing C. sativum’s effect against adult larvae in vitro they found that the hydro-alcoholic extract was more effective than the aqueous one.

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Most anthelmintics work against adult parasites by being absorbed through their skin so they offer as a possible explanation the fact that hydro-alcoholic substances are absorbed more readily [22]. The solvent that is used to extract secondary compounds affects the price of producing medicine from a plant and the ease with which extraction of secondary compounds can be carried out determines whether they might be processed locally with simple equipment [6]. A plant whose compounds can be extracted using water and a pot would obviously be a cheaper alternative than one whose compounds are only soluble in some other substance that would need to be manufactured. One of the benefits of using plant extracts is that it is significantly easier to determine and control the dose administered. A purified extract of only the active secondary compound[s] would allow even more precise dosing but in many cases the precise active compound has not been identified or the plant contains multiple chemicals that

work together to efficiently kill parasites. In these cases we cannot make a purified extract and so a crude infusion of the plant would be the next easiest to standardize. Using non-purified compounds raises its own issues as research must be done to determine how different growth conditions affect the plant’s concentration of secondary compounds [10]. In several studies of Albizia anthelmintica researchers have found that the plant’s anthelmintic activity varies greatly depending on how the treatment is prepared and where the plants are from. Arid areas seemed to be associated with more concentrated secondary compounds and thus more pronounced medicinal action [7]. The least controllable, but at times quite effective, way to administer compounds is by allowing stock free access to an anthelmintic plant. Cichorium intybus, Lespedeza cuneata, and Lotus corniculatus have all been found to affect worm load in animals grazing free-

ly on them [11, 12, 13, 23]. All of these plants are high in condensed tannins, compounds whose anthelmintic properties are widely accepted. How they act, however, is still unclear. Studies seem to indicate that it is a combination of direct action [8, 11] against nematodes and their ability to protect protein by binding to it in the rumen [the initial digestive chamber of “4-stomached” ruminants] and releasing it later in the digestive process where it is absorbed [8, 11, 24, 25]. A positive correlation exists between supplemental protein and increased immune reaction against worms [2, 8, 24, 26]. Overdosed, tannins can reduce nutritional uptake [26] but it appears possible to find a balance where the positive effects in elimination of parasites is greater than any negative impacts [24, 25].These plants might also reduce worm load because they are higher off the ground than grass and limit the re-ingestion of faeces and the parasite eggs they contain.

WHAT IS SAFE AND EFFECTIVE? Once a plant has been confirmed as an anthelmintic and different administration methods have been tested, more research is essential to establish dose guidelines and safety margins. Many people would tend to assume that because the substances in question are either plants or plant derived they are “natural” and thus “safe” [27]. In fact, plants can have very adverse and sometimes lethal effects and very small safety margins and so need to be tested for safety both for the animal receiving them and for the consumer of that animal’s products [6]. This article discusses a number of species that are, or are potentially, “effective” but this adjective hasn’t been quantified. This is another of the tasks that must be accomplished before the

place of medicinal plants in worm control can really be defined. The European Agency for the Evaluation of Medicinal Products and the FDA concur that, for an anthelmintic to be labeled as effective against a species of worm, it must eliminate at least 90% of the worm load [28]. Very few medicinal plants meet this standard, but this is no cause for dismissal. In some cases the use of sub-optimal solutions is justifiable from a purely economic standpoint. It is possible that incomplete elimination of worms is still sufficient to reduce their impact on production to a negligible level [26]. In others, it is simply a matter of “something is better than nothing” in rural and undeveloped areas where commercial dewormers are either unavailable or prohibitively expensive [7]. But farmers, veterinarians

and researchers are becoming increasingly aware that gastrointestinal parasite control is not a one-shot, one-drugfix-all problem. Rather it is a challenge that must be met by the development of many diverse and sustainable methods that can be integrated into customized systems for each farm. Such a system would account for the animals raised, the locality and the general production set up, and the management practices [6, 7, 8]. There is no doubt that the use of anthelmintic plants will be an essential component of any such system. It is therefore vital that researchers continue to identify species and conduct research that will allow medicinal plants to be safely and effectively used to their full capacity.

ARTWORK Eric Bai ‘15 SPRING 2015 || THE TRIPLE HELIX

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“

...gastrointestinal parasite control is not a one-shot, one-drug-fix-all problem.

REFERENCES [1] Eguale T, Tadesse D, Giday M. In vitro anthelmintic activity of crude extracts of five medicinal plants against egg-hatching and larval development of Haemonchus contortus. J Ethnopharmacol. 2011 Sep;137(1):108–13. [2] Wolstenholme AJ, Fairweather I, Prichard R, von Samson-Himmelstjerna G, Sangster NC. Drug resistance in veterinary helminths. Trends Parasitol. 2004 Oct;20(10):469–76. [3] Kamaraj C, Rahuman AA, Elango G, Bagavan A, Zahir AA. Anthelmintic activity of botanical extracts against sheep gastrointestinal nematodes, Haemonchus contortus. Parasitol Res. 2010 Dec 14;109(1):37–45. [4] Lans C. Validation of ethnoveterinary medicinal treatments. Vet Parasitol. 2011 Jun;178(3-4):389–90. [5] Iqbal Z, Jabbar A, Akhtar MS, Muhammad G, Lateef M. Possible Role of Ethnoveterinary Medicine in Poverty Reduction in Pakistan: Use of Botanical Anthelmintics as an Example. Journal of Agriculture & Social Sciences. 2005;1(2):187–95. [6] Hammond JA, Fielding D, Bishop SC. Prospects for Plant Anthelmintics in Tropical Veterinary Medicine. Vet Res Commun. 1997 Apr 1;21(3):213–28. [7] Gradé JT, Arble BL, Weladji RB, Van Damme P. Anthelmintic efficacy and dose determination of Albizia anthelmintica against gastrointestinal nematodes in naturally infected Ugandan sheep. Vet Parasitol. 2008 Nov; 157(3-4):267–74. [8] Shalaby HA. Anthelmintics Resistance; How to Overcome it? Iran J Parasitol. 2013 Mar; 8(1):18–32. [9] Assis L., Bevilaqua CM., Morais S., Vieira L., Costa CT., Souza JA. Ovicidal and larvicidal activity in vitro of Spigelia anthelmia Linn. extracts on Haemonchus contortus. Vet Parasitol. 2003 Nov; 117(1-2):43–9. [10] Hördegen P, Hertzberg H, Heilmann J, Langhans W, Maurer V. The anthelmintic efficacy of five plant products against gastrointestinal trichostrongylids in artificially infected lambs. Vet Parasitol. 2003 Nov; 117(1-2):51–60. [11] Min BR, Pomroy WE, Hart SP, Sahlu T. The effect of short-term consumption of a forage containing condensed tannins on gastro-intestinal nematode parasite infections in grazing wether goats. Small Rumin Res. 2004 Mar; 51(3):279–83. [12] Joshi BR, Kommuru DS, Terrill TH, Mosjidis JA, Burke JM, Shakya KP, et al. Effect of feeding sericea lespedeza leaf meal in goats experimentally infected with Haemonchus contortus. Vet Parasitol. 2011 May; 178(1-2):192–7. [13] Shaik SA, Terrill TH, Miller JE, Kouakou B, Kannan G, Kaplan RM, et al. Sericea lespedeza hay as a natural deworming agent against gastrointestinal nematode infection in goats. Vet Parasitol. 2006 Jun; 139(1-3):150–7.

”

EDITOR Hye In Sarah Lee [15] Kundu P, Laskar S. A brief resume on the genus Ailanthus: chemical and pharmacological aspects. Phytochemistry Reviews. 2009 Nov 12; 9(3):379–412. [16] Lavhale M, Mishra S. Nutritional and therapeutic potential of Ailanthus excelsa - A Review. [Internet]. 2007. Available from: http://www. phcogrev.com/text.asp?2007/1/1/105/59636 [17] Rochfort S, Parker AJ, Dunshea FR. Plant bioactives for ruminant health and productivity. Phytochemistry. 2008 Jan; 6(2):299–322. [18] Kumar D, Kumar A, Prakash O. Potential antifertility agents from plants: A comprehensive review. J Ethnopharmacol. 2012 Mar; 140(1):1–32. [19] Maciel MV, Morais SM, Bevilaqua CML, Camurça-Vasconcelos ALF, Costa CTC, Castro CMS. Ovicidal and larvicidal activity of Melia azedarach extracts on Haemonchus contortus. Vet Parasitol. 2006 Aug; 140(1-2):98–104. [20] Kamaraj C, Rahuman AA, Bagavan A, Mohamed MJ, Elango G, Rajakumar G, et al. Ovicidal and larvicidal activity of crude extracts of Melia azedarach against Haemonchus contortus [Strongylida]. Parasitol Res. 2010 Feb 23; 106(5):1071–7. [21] Akhtar M., Iqbal Z, Khan M., Lateef M. Anthelmintic activity of medicinal plants with particular reference to their use in animals in the Indo–Pakistan subcontinent. Small Rumin Res. 2000 Oct; 38(2):99–107. [22] Eguale T, Tilahun G, Debella A, Feleke A, Makonnen E. In vitro and in vivo anthelmintic activity of crude extracts of Coriandrum sativum against Haemonchus contortus. J Ethnopharmacol. 2007 Apr; 110(3):428–33. [23] Marley C., Cook R, Keatinge R, Barrett J, Lampkin N. The effect of birdsfoot trefoil [Lotus corniculatus] and chicory [Cichorium intybus] on parasite intensities and performance of lambs naturally infected with helminth parasites. Vet Parasitol. 2003 Feb; 112(1-2):147–55. [24] Nguyen TM, Binh DV, Ørskov ER. Effect of foliages containing condensed tannins and on gastrointestinal parasites. Anim Feed Sci Technol. 2005 Jun;121(1-2):77–87. [25] Terrill TH, Dykes GS, Shaik SA, Miller JE, Kouakou B, Kannan G, et al. Efficacy of sericea lespedeza hay as a natural dewormer in goats: Dose titration study. Vet Parasitol. 2009 Jul; 163(1-2):52–6. [26] Githiori JB, Athanasiadou S, Thamsborg SM. Use of plants in novel approaches for control of gastrointestinal helminths in livestock with emphasis on small ruminants. Vet Parasitol. 2006 Jul; 139(4):308–20. [27] Githiori JB, Höglund J, Waller PJ, Baker RL. The anthelmintic efficacy of the plant, Albizia anthelmintica, against the nematode parasites Haemonchus contortus of sheep and Heligmosomoides polygyrus of mice. Vet Parasitol. 2003 Aug; 116(1):23–34. [28] Messenheimer J. EFFECTIVENESS OF ANTHELMINTICS: General Recommendations VICH GL7.

[14] USDA, NRCS. 2013. The PLANTS Database [http://plants.usda.gov, 17 November 2013]. National Plant Data Team, Greensboro, NC 274014901 USA.

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Lip Lift Can Cosmetic Surgery Increase One’s Happiness? PRIYA PATEL ‘16 As cosmetic surgery becomes cheaper and safer, the number of cosmetic surgery procedures performed is increasing. In 2011, 14.7 million documented cosmetic surgeries were performed of which 4.4% occurred in South Korea, making it the seventh largest producer of cosmetic surgery worldwide [1]. Per capita, South Korea had the largest number of procedures performed, with 13.3 procedures done for every 1000 citizens [2]. The most common surgical procedures in South Korea are Lipoplasty—a removal of stomach fat, Breast Augmentation, Blepharoplasty- a reshaping of the eyes, and Rhinoplasty – a resculpting of the nose, in that order. South Korea’s cosmetic surgery industry is growing and fuel-

ling a homogenized standard of beauty throughout East Asia[1]. This surge in cosmetic surgery has many contributing factors: societal pressures to be beautiful, an idea that beauty can be attained through hard work, and perhaps the idea that beauty and happiness are intrinsically linked together. For modern Korean women, being conventionally beautiful means having a small face, large eyes, and a high, sharp nose. It is no surprise that blepharoplasties and rhinoplasties are among the most common surgical procedures, as they enlarge the eyes and modify the nose, respectively [3]. Many plastic surgery clients look to Korea’s actresses and Kpop stars for inspiration.

They want to look like Shin Min-a or Kim Tae-hee, actresses with large eyes, pointy noses and slender jaw lines [4]. These women aspire to beauty standards that seem somewhat arbitrary-where do these standards come from? Numerous research papers that talk of “golden ratios” that exist in attractive female faces. For example, it has been proven that the most attractive ratio between interocular distance- the distance between the eyes- and total face width is .45[5]. However, many of these studies use Caucasian women as their subjects, and therefore, are most certainly biased [5,6]. There has been one study showing that ethnically Korean women have statistically differ-

PHOTOS Kaley Brauer ‘17 46

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Researchers have hypothesized human emotion to be a sort of feedback loop, wherein expression of an emotion amplifies the experience of that emotion, rather than just being a consequence of it.

ent facial ratios than North American white women. In this study, ethnically Korean women were categorized as either “average” or “attractive” by other Korean women. The “attractive” Korean women had facial proportions that were much closer to those of the average North American white woman. This outcome is deeply unsettling. The judges of attractiveness were themselves, ethnically Korean, but their definition of beauty was highly biased in favor of women who shared facial proportions with North American white women [7]. This suggests a homogenization of beauty standards. Globally, it appears that there can only be one “beautiful,” and it is this beauty that many of the consumers of cosmetic surgery strive for. Regardless of where beauty standards have come from, they are present and difficult to escape. Although the origin of rigid ideals of beauty are difficult to trace, the motivations behind conforming to these standards are easy to comprehend. It’s hard to stay competitive in service jobs in Korea if one hasn’t had some of these procedures, as job applications can require a headshot submission. Effectively, a person’s attractiveness is judged alongside his or her professional qualifications [2]. In this environment, it is difficult to not conform to the cosmetic surgery standards, lest one sabotage his or her future employment opportunities. Procedures like blepharoplasty are

thought to make the face look more alert and inviting [8]. For service sector employers, then, it would make sense to want employees to appear as attentive and attractive as possible. The vast pool of cosmetically enhanced potential employees in South Korea makes it almost unwise to not have some sort of procedure done to align oneself with the accepted beauty standard. Being beautiful is not so much a luxury as a tool for survival. In addition to the common procedures, like blepharoplasty, rhinoplasty and jaw reshaping, a new surgery has come into the forefront- a variation on Valentine Anguloplasty, or smile surgery, that is supposed to make the patient seem more pleasant and inviting. Within this past year, the company Aone has patented its own version of Valentine Anguloplasty, named “Lipt,” as a combination of the words “lip” and “lift.” Valentine Anguloplasty, historically, has been used to try and correct a drooping, downturned mouth. Aone claims that it corrects the downward turned mouth by actually changing the “muscle balance” of the mouth. This is supposed to yield longer lasting results than traditional anguloplasties consisting only of skin excisions [9]. In typical western cosmetic surgery, the correction of an excessively drooping mouth is done by injecting the muscle with botulinum toxin (often referred to as “Botox”), and soft tissue implants.

Soft tissue implants are materials used as fillers for certain facial structures [10]. However, the botulinum/implant combination, though longer-lasting than soft tissue implants alone, has a finite longevity, and the patient must have consistent remolding of the implant and re-injection of botulinum toxin. Aone boasts a longer, more permanent solution to downturned mouth corners through Lipt. Aone does not highlight the potential neurological and social effects of Lipt, and how changing facial expression can directly impact a person’s mood. The Lipt procedure involves cutting a part of the modiolus, a disk-shaped group of muscles located at the corners of the mouth, thereby weakening the muscles that cause a person to frown. Frowning is induced by the contraction of the depressor anguloris muscle located in the modiolus, and weakening it can cause a more naturally upturned mouth. Can this perpetual, subtle smile actually make someone happier? Beyond the seemingly obvious happiness that comes from feeling more attractive, Lipt has the potential to neurologically improve the moods of its recipients, simply by making frowning more difficult. According to one study, women who were unable to frown due to a botulinum toxin injection of their corrugator muscles (which are located above the eyes) tended to report better moods, and tended to show fewer negative emotions than those women who

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BEFORE

were able to fully frown. Researchers have hypothesized human emotion to be a sort of feedback loop, wherein expression of an emotion amplifies the experience of that emotion, rather than just being a consequence of feeling it. If someone cannot express negative emotions with his or her face, then that person feels less negativity [11]. The idea that the facial expression and the emotion share a causative, as well as a correlative relationship has been tested since the late 20th century, with researchers Adelmann and Zajnoc observing that patients forced to smile found cartoons to be funnier. Then researcher Jonathan Cole observed that patients with facial paralysis caused by a genetic disorder, Mobius syndrome, were also much less able to feel common emotions. Furthermore, increased corrugator activity has been linked to anxiety and other disorders [12]. This link between expressing emotion and feeling it has been used as far as to attempt to treat depression. One study showed that nine out of 10 depression patients injected with botulinum toxin in the glabellar frown lines, located at the inner corners of the upper eye,

AFTER*

did not show depression signs upon follow-up [11]. These results indicate that expression is integral to feeling and that human’s faces are not merely facades, but rather an integral part of emotional responses. The inability to express an emotion does not only affect the person making the expression; third-party observers can interpret an emotional expression, regardless of how the maker of the facial expression intends to be seen. In one study, people who could not frown due to injection of botulinum toxin were photographed making the same facial expressions before and after their injections. Participants were able to rank the pre-injection photos as more angry or sad than the post-injection photos. The “after” photos were described as “expressing more happiness and less anger, fear, and sadness [13].” The injection of botulinum toxin involuntarily restricted the frowning facial expressions in the photographed participants of this study, and the subjects viewing the photos could grade the intensity of emotion accordingly. Then if someone were to put forth a perpetually happy face, even uninten-

tionally, observers would notice. Further adding to the impact of a facial expression, there is also research to indicate that an observer undergoes an involuntary amygdallar reaction to emotions expressed by others. Even before there is a conscious interpretation of a facial expression, the brain responds. In one research experiment, fearful, happy and neutral faces were shown to participants, and there was significant amygdala activity in response to emotive faces as opposed to neutral faces. Clasically, amygdallar responses are associated with fear, but this study showed that the left anterior amygdala was also stimulated when observing a happy facial expression [14]. This shows that human brains have an involuntary, measurable, response to displayed emotions, and that the mood people convey to the world has a real and neural effect on others. A surgery like Lipt can make a person always appear slightly smiling, and looking happy all the time can subtly cause others to feel happiness. If Lipt can induce an improved mindset in patients and the people they interact with, then perhaps this surgery is a positive

* NOTE: These are merely a photoshopped example as opposed to actual before and after pictures.

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A surgery like Lipt can make a person always appear slightly smiling, and looking happy all the time can subtly cause others to feel happiness.

thing- a way to spread brighter moods. To some, the increasing demand for surgically attained beauty is troubling. Cosmetic surgery is seen as a sign of vanity or shallowness. There are people who openly criticize South Korea’s beauty standards on popular websites like BuzzFeed [15, 16,17] , while simultaneously ignoring what beauty means

to South Koreans. Beauty, however members of a society choose to define it, can have a profound influence on people, both subjectively, and objectively. There is a neurological correlation between the faces one makes and sees and how happy a person feels [10]. Maybe the desire to look beautiful, always smiling, or always bright-eyed and alert doesn’t stem from person-

REFERENCES [1] International Society of Aesthetic Plastic Surgery. ISAPS International Survey on Aesthetic/Cosmetic Procedures Performed in 2011 [Internet]. 2011. [cited November 13, 2013]. Available from: http://www. isaps.org/files/html-contents/Downloads/ISAPS%20Results%20-%20 Procedures%20in%202011.pdf [2] Lee, Heesu, Bloomber Businessweek. Perfecting the Face Lift, Gagnam Style [Internet]. October 10, 2013. [cited November 12, 2013]. Available from: http://www.businessweek.com/articles/2013-10-10/plastic-surgery-lifts-south-korean-tourism [3] Stone, Zara, The Atlantic. The K-Pop Plastic Surgery Obsession [Internet]. May 24, 2013, [cited November 12, 2013]. Available from: http://www. theatlantic.com/health/archive/2013/05/the-k-pop-plastic-surgery-obsession/276215/ [4] Kim V. CNN Travel. Welcome to the Plastic Surgery Capital of the World [Internet]. August 9, 2012 [cited November 13, 2013]. Available from. http://travel.cnn.com/seoul/visit/ideals-beauty-plastic-surgery-capital-world-389581 [5] Pallett PM, Link S, Lee K. New ‘‘golden” ratios for facial beauty. Vision Research 2010; 50:149-154. [6] Cunningham MR, Measuring the physical in physical attractiveness: Quasi-experiments on the sociobiology of female facial beauty. J Personality and Social Psychology 1986; 50(5):925-935. [7] Choe KS, Sclafani AP, Litner JA, Yu G, Romo T. The Korean American Woman’s Face Anthropometric Measurements and Quantitative Analysis of Facial Aesthetics, JAMA Facial Plastic Surgery 2004; 6(4):244-252. [8] Haddrill M. Eyelid Surgery for a More Youthful Appearance [Internet]. May 2013. [cited November 12, 2013]. Available from http://www. allaboutvision.com/cosmetic/blepharoplasty.htm

al vanity. Perhaps wanting to present a surgically-altered, conventionally beautiful face to the world is an attempt to bring happiness to oneself and others. While some may argue that going under the knife is excessive, or that the standards of beauty are narrow and unforgiving, no one can deny the legitimacy of the desire to spread happiness.

EDITOR Methma Udawatta [9] Mouth Corner Lip Surgery (Smile Lipt) .Aone Plastic and Aesthetic Surgery[Internet]. [cited November 12. 2013]. Available from: http:// eng.aone.ac/ [10] Carruthers J, Carruthers A. Aesthetic Botulinum A Toxin in the Mid and Lower Face and Neck. Dermatologic Surgery 2003; 29(5):468-476. [11] Finzi E, Wasserman E. Treatment of Depression with Botulinum Toxin A: A Case Series. Dermatologic Surgery 2006; 32(5):645-650. [12] Adelmann PK, Zajonc RB. Facial Efference and the Experience of Emotion. Annual Review of Psychology ; 40:249-280. [13] Teichmann B, Schroder U, Sprengelmeyer R, Ceballos-bauman, Ao. Pharmacologic denervation of frown muscles enhances baseline expression of happiness and decreases baseline expression of anger, sadness, and fear. J American Academy of Dermatology 2003; 49(2):213-216. [14] Breiter HC, Etcoff NL, Whalen PJ, Kennedy Wa, Rauch Sl, Buckner Rl, et al. Response and Habituation of the Human Amygdala during Visual Processing of Facial Expression. Neuron 1996; 17(5):875-887. [15] Perez A. Buzzfeed. I Wasn’t Beautiful Enough to Live in South Korea [Internet]. May 31, 2013[ cited November 12, 2013]. Available from: http://www.buzzfeed.com/ashleyperez/i-wasnt-beautiful-enough-tolive-in-south-korea [16] Broderick R. Buzzfeed. Plastic Surgery that Forces you to Smile Uncontrollably Is All the Rage Among South Korean Women [Internet]. August 28, 2013 [cited November 12, 2013]. Available from http://www. buzzfeed.com/ryanhatesthis/plastic-surgery-that-forces-you-to-smileuncontrollably-is-a [17] Odell A. Buzzfeed. Has Plastic Surgery Made These 20 Beauty Pageant Contestants Look the Same? [Internet]. April 24, 2013. [cited November 12, 2013]. Available from: http://www.buzzfeed.com/amyodell/hasplastic-surgery-made-these-20-korean-beauty-pageant-cont

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EXPLORING THE

Earthy Scent

OF WET DIRT

LUCY VAN KLEUNEN ‘17

Maybe you’ve never heard of geosmin, but you know it well. An organic compound produced by soil bacteria, geosmin is responsible for a scent that is recognizable, ubiquitous, and evocative – that of your grandmother’s garden or canoe trips; the earthy flavor of beets, spinach, mushrooms, and catfish [1][2]. Geosmin, which is Greek for “earth odor,” is one of the molecules responsible for the characteristic smell of moist soil [3][4]. Most humans can smell geosmin in concentrations as low as 0.7 parts per billion, meaning that “if you poured a teaspoon of geosmin into the equivalent of 200 Olympic-sized swimming pools, you would still be able to smell it” [1][2].No one knows for sure where this sensitivity has come

from, but some have speculated that it could relate to prehistoric survival, developed as a way for our ancestors to find sources of water [1]. David Cane, a biochemist a Brown University, has been interested in this organic molecule for a long time. His exploration of the biochemical origins of geosmin has both opened doors to a comprehensive understanding of soil ecology and helped solve a practical problem faced by many municipalities— that of drinking water purification. Geosmin is produced by a variety of microbes, cyanobacteria, and fungi including S.coelicolor. a species of filamentous dirt bacteria [5]. In 2007, Cane and a team of Brown University

biochemists discovered the sequence in the S. coelicolor genome responsible for producing geosmin. This gene triggers a mechanism by which a single protein within the bacteria produces the compound in a two part reaction [6]. This was the first work done on the mechanism of geosmin biosynthesis since the 1980’s [7]. Amongst soil bacteria, S. coelicolor has been one of the most widely studied genetically, and was completely sequenced in 2002[8]. Scientists like Cane have been able to identify the genes connected to many of the processes within the bacteria that create organic compounds. Many of these compounds are of potential therapeutic

PHOTOS Kaley Brauer ‘17

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SEE THAT DOT TO THE LEFT? The human nose is so sensitive to geosmin that if that dot was geosmin and every page of this magazine was part of one large body of water, we would still be able to smell the geosmin. In fact, even if the magazine was twenty times larger, we’d still be able to smell it.

use. Dirt bacteria such as S. coelicolor are responsible for the production of “anti-tumour agents, immunosupressants and over two-thirds of all natural antibiotics currently available” [9]. Although a rise in adaptive microbial resistance to these organically produced drugs has reduced their popularity, biochemists have continued this research in order to understand the processes that can lead to antibiotic production [10]. It was during such pharmaceutical research that Cane and his team unexpectedly discovered the source of dirt’s odor. The practical application of this discovery is not immediately apparent- the earthy geosmin scent is often positively associated with fond memories of rainy soccer games or camping trips. However, when one thinks of finding the same smell in a glass of water, the potential relevance of the discovery becomes clear. There is no consensus in the biochemistry community as to why we now find a taste that does not alert to any toxicity unpleasant [11]. This preference can become a big problem for municipalities which have experienced blooms of cyanobacteria, commonly called blue-green algae [12]. During summer months, when high phosphorous and nitrogen concentrations spur these blooms in reservoirs, water systems receive complaints from users about musty and dirty tastes in their water attributed to geosmin produced by cyanobacteria . Although drinking geosmin is not harmful for humans, cities do not want to provide their con-

stituents with dirty-tasting water. This compound can become a significant contaminant in very small quantities due to our sensitivity to the scent [12]. In order to address this problem, Cane and other researchers developed an easy methodology for testing water for the presence of geosmin. Because the geosmin-synthesizing gene is now known, they found they could use simple PCR technology, which can detect the presence of a specific chain of genes [13]. There are plans to turn this water test into a field kit that cities can use to test their reservoirs [11][14]. In October of 2011, Brown submitted a patent application for this method [15]. The most significant use for this fieldkit is in early detection of geosmin contamination. If cyanobacteria blooms are allowed to spread for a long time, removal techniques become costly and inefficient. Sprinkling granular activated carbon to absorb the bacteria or setting up biofilm-containing sand filters can relieve the problem, but both methods are highly dependent on contact time and water quality [12]. Oxygenating the source water using ozone both kills oxygen-hating anaerobic bacteria and pushes surface-dwelling cyanobacteria into the depths where they die due to lack of sunlight [16]. While this method can be cost-effective in long run, it involves initial high capital investment [12]. Some bacteria can use geosmin as a fuel source and thus organically deplete the level of these compounds, but this has only

been successful so far in controlled laboratory situations [17]. Amongst these methods, there is no procedural solution, and often blooms are contained by some combination found through trial and error [18]. In addition to water treatment facilities, the troubles of geosmin decontamination can also affect the fishing and wine industries. Geosmin contamination in a fish farm can mean several days of purging off-flavored fish with clean water before marketing, inflicting considerable financial losses on the aquaculture industry [17]. Similarly, if a few tiny drops of geosmin find their way into a fermenting wine barrel, makers must rush to salvage their supply, often using grape seed oil as a type of solvent for the geosmin. This too, can prove to be an inconvenient and often inefficient technique [1]. In both situations, Cane’s genetic field test would allow for earlier detection and isolation of geosmin contamination. In 2008, Cane and the team compared geosmin production in cyanobacteria, which is the usual culprit for geosmin contamination in water, to that in S.coelicolor, the bacteria they originally analyzed. They found that in both species of bacteria, virtually the same biochemical reaction was catalyzed to produce geosmin. This production was the result of a single mutation in both bacteria’s the DNA sequences that were of similar length. In fact, when they studied this production in still other bacteria species, they noticed that their geo-

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smin producing genes were also very similar. Amongst the geosmin synthesis genes in cyanobacteria, S.coelicolor, and various other geosmin-producing organisms, there were “correspondingly high levels of sequence conservation over all 730-740 amino acids.” All species that produce geosmin do so in virtually the same way- with the same genetic sequence and virtually the same catalyzed enzymes [14]. This genetic similarity becomes an important tool for solving the pesky problem of contamination source detection in reservoirs. Before any decontamination methods are even tried, industry officials must identify the source of the contamination. Cyanobacteria blooms are often difficult to isolate to a particular area, and furthermore cannot always be attributed as the sole cause of soil-taste in water [11]. Dr. Susan B Watson of the Canada Centre for Inland Waters in Burlington, Ontario, is an expert on the ecological and socioeconomic effects of source-water toxins and blooms. Her research has shown that in many cases of geosmin contamination, cyanobacteria were not even present in high quantities [19][5]. Geosmin can find its way into reservoirs from a number of sources, including other bacteria or even biofilm buildup on water-channeling pipes [5]. This means that methods such as filtration, which specifically target blue-green algae, will not necessarily stop the water from smelling like soil. To further complicate source identification, considerable expertise is required to identify geosmin-producing cyanobacteria microscopically [19]. As techniques to

distinguish between species of bacteria have become more advanced and classification has become more rigorous, “many species identified as geosmin… producers by early studies have since been renamed, leading to confusion ”[19]. The geosmin-detecting PCR test can help solve this problem. Along with being able to detect geosmin contamination in early small quantities, these tests have the additional advantage of being able to differentiate amongst geosmin producing species. For those running the water systems in small, often rural, municipalities, containing geosmin contamination can become extremely frustrating and costly. The PCR test that Cane has helped develop assists cities in two ways. First, it helps them detect geosmin contamination earlier. Then, it helps them identify its cause, thereby taking the guessing game out of containment strategies. With such a tool, municipalities could easily take regular tests across their reservoirs in order to pinpoint, monitor, and contain the presence of geosmin-producing microbes. Unfortunately, according to Professor Cane, it is not feasible to use the genetic discovery to bioengineer non-geosmin-producing bacteria or alter the genetic signature of cyanobacteria in reservoirs. There would be no way to efficiently treat a lot of water to specifically target and deactivate certain gene proteins in a wide variety of bacteria. Because the water would need to remain potable, any such method would also need to be screened for possible

toxic effects. Removing the bacteria, genetically engineering them to not produce geosmin, and then introducing them back into the environment could have unknown ecological effects. Instead, understanding the mechanism by which geosmin is produced can lead to development of early detection methods, such as the PCR test, that can more easily identify and target a source of geosmin production- such as a cyanobacteria bloom- before it becomes a huge problem [11]. Despite the significant practical applications of his discovery, what Cane finds most fascinating about his work is its potential for revolutionizing our fundamental understanding of soil ecosystems. Because the gene sequence that causes geosmin production has been highly conserved across a wide variety of bacterial species, it must be important. In other words, as the bacteria evolved and differentiated, the geosmin-creating gene stayed virtually the same. This reaction must then have an evolutionary or environmental function [11]. So far, this function has not been definitively identified. A common theory is that species, including humans, have developed high sensitivities to geosmin in order to aid their own survival. Professor Keith Chater, in an article in The Guardian after his team at the John Innes Centre in Norwich independently discovered the function of the geosmin-producing genetic sequence, speculated that camels could follow the geosmin scent to find water in the desert and that geosmin-producing

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bacteria could be spreading the scent in order to find hosts, like camels, to carry their spores [20]. Neither part of this theory, however, has been backed by any empirical data. Geosmin has also “been proposed as a chemical land mass homing signal for anadromous [migrating] fish,” and there has been some circumstantial evidence for geosmin’s attraction of worms and eels [5] [11]. Now that the genetic sequence controlling geosmin production has been discovered, experiments can be performed in which the genetic code of a typically geosmin-producing bacterium is altered to limit geosmin production. This bacterium could then be

monitored in various controlled and natural environments to determine the ecological function of the mechanism that produces the smell [11]. Beyond the potential for these interesting applications, the biochemistry community has also found this discovery significant as an interesting “scientific problem” in itself [11]. The protein that completes geosmin production is shaped like a dumbbell in which one side completes half of the reaction and the other completes the second. This is the first bifunctional enzyme found for the production of the type of terpene, or class of organic molecule, to which

REFERENCES [1] Howes Laura. Geosmin. Royal Society of Chemistry. [Internet]. [cited 2013 Oct 21]. Available from: http://www.rsc.org/chemistryworld/podcast/CIIEcompounds/transcripts/geosmin.asp [2] Halifax Regional Municipality. Geosmin Frequently Asked Questions. [Internet]. 2013 Oct [cited 2013 Oct 21]. Available from: https://www. halifax.ca/hrwc/Geosmin_FAQ.html [3] Cotton, Simon. Geosmin. Uppingham School. [Internet] 2009 Aug [cited 2013 Oct 21]. Available from: http://www.chm.bris.ac.uk/motm/ geosmin/geosminh.html [4] Trojan Technologies. Taste-And Odor-Causing Compounds in Drinking Water. [Internet]. 2005 [cite 2013 Oct 21]. Available from: http://www. engamerica.com/uploaded/Doc/Trojan_ECT_Facts.pdf [5] Juttner F, Watson SB. Biochemical and Ecological Control of Geosmin and 2-Methylisoborneol in Source Waters. J Applied and Environmental Microbiology [Internet]. 2007 July[cited 21 Oct 2013]; 73(14):4395-4406. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1932821/ [6] Coyle Ann. Brown Chemists Explain the Origin of Soil-Scented Geosmin. Brown University News.[Internet]. 2007 Sep 16 [cited 2013 Sep 25]. Available from: http://news.brown.edu/pressreleases/2007/09/ origin-soil-scented-geosmin [7] Meganathan R.What Causes the Characteristic Smell of Soil? Northern Illinois University Department of Biological Sciences. [Internet]. 2013 [cited 2013 Oct 21]. Available from: http://www.bios.niu.edu/ meganathan/smell_of_soil.shtml [8] Bentley SD, Chater KF, Cerdeno-tarraga AM, et al. Complete genome sequence of the model actinomycete Streptomyces coelicolor A3(2). J Nature [Internet]. 2002 May 9 [cited 21 Oct 2013]; 417:141-147. Available from: http://www.nature.com/nature/journal/v417/n6885/full/417141a. html [9] Sanger Institute. Streptomyces coelicolor. [Internet]. 2013 Apr 03 [cited 2013 Oct 21]. Available from:http://www.sanger.ac.uk/resources/ downloads/bacteria/streptomyces-coelicolor.html [10] Pearson Education- infoplease. Production of Antibiotics. [Internet]. 2013 [cited 2013 Oct 21]. Available from: http://www.infoplease.com/ encyclopedia/science/antibiotic-production-antibiotics.html

geosmin belongs. The team is still piecing together the biochemical puzzle posed by this completely unexpected mechanism in the geosmin-producing reaction [13]. Whether at this deep academic level, in the practical problem of drinking water purification, or in broad theoretical questions about the role of scent in soil ecology, there is much more to the smell of dirt than worms and mud-pies. The next time you step outside on a rainy day, take a moment to appreciate the fresh earthy scent which greets you. It is proof that right under your feeta fascinating reaction is taking place to produce geosmin, nature’s mysterious perfume.

EDITOR Mali’o Kodis [11] Cane David. Interviewed by: Lucy Van Kleunen. 2013 Oct 15 [cited 2013 Oct 21]. [12] Microbac Laboratory Services. Geosmin and MIB and Resulting Taste and Odor Problems in Finished Drinking Water. [Internet]. 2011 [cited 2013 Oct 21]. Available from: http://www.microbac.com/uploads/ Technical%20Articles/pdf/Geosmin%20and%20MIB%201.pdf [13] Research at Brown: The Directory of Research and Researchers. David Cane. [Internet]. 2012 [cited 2013 Oct 21]. Available from: https:// research.brown.edu/myresearch/David_Cane [14] Giglio S, Jiang J, Saint CP, Cane DE, Monis PT. Isolation and Characterization of the Gene Associated with Geosmin Production in Cyanobacteria. Environ. Sci. Technol [Internet]. 2008 [cited 2013 Oct 21]; 42:8027-8032. Available from: http://pubs.acs.org/doi/pdf/10.1021/es801465w [15] Cane D, Giglio S, Jiang J, Saint CP, Monis PT. Methods of Detecting Sources of Microorganism Contamination. United States Patent Application 0250604, Oct.2011. [16] Clean-Flo. A Natural Method of Reservoir Restoration. [Internet] 2013 [cite 2013 Oct 21]. Available from: http://www.clean-flo.com/systems/ reservoir-restoration/ [17] Guttman Lior, van Rijn Japp. Isolation of Bacteria Capable of Growth with 2-Methylisoborneol and Geosmin as the Sole Carbon and Energy Sources. J Applied and Environmental Microbiology [Internet]. 2011 [cited 2013 Sep 25]; 78(2): 363-370. Available from: http://aem.asm. org/content/78/2/363.full [18] New Hampshire Department of Environmental Services. Cyanobacteria and Drinking Water: Guidance for Public Water Systems. [Internet] 2009 [cited 2013 Oct 21]. Available from:http://des.nh.gov/organization/ commissioner/pip/factsheets/dwgb/documents/dwgb-4-15.pdf [19] Environment Canada. Dr. Susan B. Watson. Government of Canada. [Internet]. 2013 Aug 29 [cited 2013 Oct 21]. Available from: http://www. ec.gc.ca/scitech/default.asp?lang=En&n=F97AE834-1&formid=20E3A 86D-215C-45C8-8942-C21E20E8EDA6&xsl=scitechprofile [20] Simons, Paul. Camels act on a hump. theguardian. [Internet]. 2003 March 5 [cited 2013 Oct 21]. Available from: http://www.theguardian. com/science/2003/mar/06/science.research/print

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