EURJ Volume 15 by Emory Undergraduate Research Journal

EURJ

Emory Undergraduate Research Journal Volume XV

Photo by Steven Chen Instagram: @choochoo_chen

Spring 2019

about EURJ

The Emory Undergraduate Research Journal (EURJ) is an annual print and online publication that accepts research manuscripts written by Emory undergraduates from all academic disciplines. EURJ provides a venue for students to showcase their high quality, original research while fostering interest in undergraduate research. Research can be submitted up until two years post-graduation. EURJ was founded through generous support by the Office of Undergraduate Education and is continuously supported by the Media Council.

Emory Undergraduate Research Journal Volume XV Spring 2019

1655 North Decatur Road, Atlanta, Georgia 30322

A Letter from Undergraduate Research Programs The College of Arts and Sciences at Emory has long supported undergraduate research efforts in exploring, creating, and furthering research efforts in all disciplines. The current leadership team of Undergraduate Research programs is excited to support the university’s mission to serve a vibrant community of undergraduate researchers. Our office is dedicated to facilitating student experiential learning opportunities to ensure that their passions and interests are fully realized. In collaboration with EURJ, we seek to promote the ideas of Emory’s undergraduate research community through student profiles and articles. This volume showcases the breadth of research present at Emory in the humanities, social sciences, and natural sciences. The students featured in this volume further the narrative of what defines research and how it is conducted. Journal editors have encapsulated a vibrancy of knowledge that is energized by topics which redefine how technology shapes the experience of human aging to the ethical implications of land-use projects. These articles demonstrate how Emory undergraduates are forming connections as their curiosity expands from the classroom, to the bench, and beyond. In contingence with EURJ, Emory shares undergraduate successes and intellectual pursuits through the Researchers of Emory blog. The symbiotic connection in these Emory publications assists the undergraduate student body to inquire, question, and transform the landscape of academia. We at Undergraduate Research Programs are proud of the efforts of EURJ’s editorial team. We hope this issue provides insight to broaden your understanding of research at Emory.

Dr. Cora Macbeth Assistant Dean, Emory Undergraduate Research Administrative Assistant, Brenda Nix Program Coordinator, Margaret Avera Grad Assistant, Max Cornely

Editorial Board 2018 - 2019 Editor-in-Chief Josh Buksbaum

Design and Layout Merry Chen Katharine Yan Ursula Choi Abhinav Nair Sanim Choudhury Daisy Li

Managing Editors Merry Chen Steven Chen Treasurer Katharine Yan

Website Editor Abhinav Nair

Humanities Editors Davis Madeja Julie Park Camilla Li

Photographer Steven Chen

Natural Sciences Editors Alexis Capobianco Landi White Alice Yang Sanim Choudhury

Copy Editor Amulya Marellapudi Special Features Camilla Li Natalia Brody

Social Sciences Editors Amulya Marellapudi Petar Zotovic Caroline Lee

Photo by Steven Chen Instagram: @choochoo_chen

Join us! Email eurjstaff@gmail.com with any questions or comments! Apply for a position on our staff or send in your research paper for publication in the Spring 2020 issue. Email us for information regarding submission guidelines and deadlines.

A Letter from the Editor: To our readers, We are pleased to present Volume 15 of the Emory Undergraduate Research Journal (EURJ). This year’s edition continues with our tradition of providing an interdisciplinary platform for undergraduates to showcase their research in the natural sciences, social sciences, arts, and humanities. Our journal seeks to highlight the intellectual vitality of the undergraduate students and recognize their scholarly work in a manner that fosters discussion. The articles in this issue were selected to provide a small glimpse into the variety and breadth of the research opportunities and topics undertaken by students. This year, we received a large number of submissions, many of which focused on different areas within the environmental science, biology, and biomedical fields. Kyla Wickens explores the doctor-patient relationship in her research article “How does a Patient’s Occupational Status Influence a Doctor-Patient Relationship and The Satisfaction Rates of Overall Health Care systems like the NHS?” Annie Schiffer examines a rare type of angiosperm in her paper “A Study of the Environmental Conditions that Influence the Presence of Rare Basal Angiosperm Schisandra glabra (Brickell) Rehder.” Grace Xu explores the impact of telehealth on quality healthcare in her paper “Telehealth & Aging - Impact of Technology on Development in Later Life.” Ishan Saran, et. al. evaluate ecosystem services in their paper “Evaluation of Ecosystem Services.” Tenzin Dudul Taklha presents humanity-based research in Asian studies, with his paper “The Significance of the Fifth Dalai Lama’s Visit to the Qing Court in 1652-1653.” These original research papers demonstrated high levels of research skill across a wide range of disciplines. We would like to express our gratitude to all of the the people whose work and support have made this journal possible. In particular, we would like to recognize our faculty advisor and director of the Undergraduate Research Programs, Dr. Cora Macbeth, who has provided us with the resources and insight to ensure the success of the journal. We greatly appreciate and thank all of the authors who submitted their research papers for review as well as their mentors. Finally, we would like to give a huge thank you to our editorial staff, whose tireless efforts and ideas have made this journal possible. On behalf of the entire 2018-2019 EURJ staff, we would like to thank you for reading the journal and we hope you enjoy the exceptional work that our Emory undergraduate students have produced.

Josh Buksbaum Editor-in-Chief

TABLE OF CONTENTS 8

A Study of the Environmental Conditions that Influence the Presence of Rare Basal Angiosperm Schisandra glabra (Brickell) Rehder

How does a Patient’s Occupational Status Influence a Doctor-Patient Relationship and the Satisfaction Rates of Overall Health Care Systems like the NHS?

Special Feature: Dr. Sarah Fankhauser

Telehealth and Aging: Impact of Technology on Development in Later Life

Evaluation of Ecosystem Services

From Lhasa to Beijing: The Significance of the Fifth Dalai Lama’s Visit to the Qing Court in 1652-1653

Photo by Steven Chen Instagram: @choochoo_chen

Environmental Conditions that Influence the Presence of Rare Basal Angiosperm Schisandra glabra (Brickell) Rehder Annie Schiffer

Pexel

ECOLOGY

Abstract

Schisandra glabra (Brickell) Rehder, or the American starvine, is a rare basal angiosperm and the only member in the family Schisandraceae found in the Americas—more specifically in rare old-growth forests. Although phytochemical and phylogenetic analyses have been conducted on S. glabra, little is known about the ecological factors that lead to S. glabra’s presence. In this study, we investigated the environmental conditions of the habitats in which S. glabra grows. Data were collected in five separate S. glabra locations within Lullwater Preserve in Atlanta, Georgia. Using the center of the patch of S. glabra as the origin, two transects were established, one parallel and one up the hills where the plant grew. The following environmental factors were then measured along two gradients in five-meter intervals: canopy density, Fagus grandifolia (American beech) density, Carpinus caroliniana (American hornbeam) density, invasive species density, soil pH, percent soil moisture, light relative to the origin, and slope of the hill. We found that canopy density significantly increased as distance from the center of the patch increased, indicating that S. glabra prefers tree gaps. F. grandifolia may influence S. glabra presence, as the tree’s density increased as distance from the center increased. Soil pH did not differ significantly along the gradient but was notably less acidic than the typical soil pH of oak-history forests. Other factors, including invasive species density, may have been influenced by anthropogenic disruption. Overall, an understanding of the environmental conditions of S. glabra’s habitat is critical for preserving this endangered vine, initiating reintroduction projects, and furthering ethnobotanical research. S. glabra presence in an old-growth forest indicates a delicate terrestrial ecosystem containing valuable and rare organisms.

Introduction

Schisandra glabra (Brickell) Rehder is a deciduous woody vine in the Schisandraceae family, commonly known as bay starvine, magnolia vine, or American starvine. The basal angiosperm is monoecious and imperfect, with either pistillate or staminate flowers (Lyles et al. 2017). The elliptical leaves are alternate but appear whorled at the tips of short lateral shoots (Panero and Aranda 1998, Lyles et al. 2017). S. glabra is the only species within Schisandraceae that is found in the Americas. Small populations are found in the Southeastern United States and in the cloud forest of the Hildago state in Mexico (Panero and Aranda 1998). Its closest relatives are Schisandra chinensis, Schisandra bicolor, and Schisandra repanda, all of which are native to East Asia (Fan 2010). Unlike its Asian counterparts, S. glabra is considered threatened or endangered in the majority of its range. In 1975, the Smithsonian Institution proposed to add S. glabra to the federal list of endangered and threatened species (Ettman 1980). In Georgia, it is considered threatened and is protected by the Georgia Department of Natural Resources (USDA 2018). Deforestation, competition from invasive species, and river impoundment reduce and fragment populations of the vine in North America (Chafin 2008, Valente 2007). The invasive species Lonicera japonica (Japanese honeysuckle) and Hedera helix (English ivy) are particularly threatening to S. glabra populations (Chafin 2008). The fragmented distribution can act as a barrier to gene flow, consequently reducing the genetic diversity of S. glabra (Chafin 2008). Maintaining the sizes of existing populations is imperative for the propagation of the species (Valente 2007). Furthermore, identifying and protecting S. glabra’s habitat enables researchers to explore its phytochemistry and bioactive properties. Already, Szopa et al. (2018) found that the chemical composition of certain species belong-

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ing to the Schisandra genus makes them phytotherapeutic of hill, (6) soil moisture, (7) density of F. grandifolia, and (8) in nature. Preliminary phytochemical analyses of S. glabra density of C. caroliniana, on S. glabra presence along two suggest the presence of novel, untapped medicinal com- transects. Linear regressions were used to analyze the facpounds in the woody vine. Lyles et al. (2017) reveal simi- tors along the transects, as proximity to S. glabra changes. larities between the chemical compositions and bioactivity We predicted that sunlight intensity would decrease, while of S. glabra and S. chinensis, a relative with a long history invasive species density, canopy density, C. caroliniana denof use in traditional Chinese medicine. S. chinensis extracts sity, and F. grandifolia density would increase as distance are traditionally used to treat a wide range of ailments in from the center of the S. glabra patch increased. In terms of Chinese and Russian medicine (Panossian and Wikman hill slope and soil factors, we predicted that the slope would 2008). Efforts to conserve S. glabra and to restore its habitat remain constant but non-zero, and soil moisture and pH could allow us to tap into its unexplored medical properties would remain constant. (Lyles et al. 2017). Although literature on the ecology of S. glabra is Methods limited, Ettman (1980) found several ecological conditions Experimental Design Data were collected in November at Lullwater Prethat were consistent in S. glabra sites across the Southeast. In Georgia, S. glabra can be found on north-facing slopes serve, an oak-hickory forest near Emory University in Atof mesophytic old-growth forests, near major streams (Ett- lanta, Georgia. Five sites known to contain S. glabra were seman 1980). The liana forms dense patches on the ground lected within the preserve. Within each site, an origin point or climbs understory trees up to five meters high (Ettman in the center of the S. glabra patch and two transects were 1980, Carl Brown, personal communication). S. glabra’s established: one parallel to the slope of the hill and one exhabitat is characterized by a richness of species that can only tending directly up the slope. The transects were 20 meters be found in post-climax communities (Ettman 1980). The long, and data were collected at the origin and every five common species found in this habitat include Fagus grandi- meters along each transect. At each interval along the transects, sunlight, canfolia (American beech), Liriodendron tulipifera (tulip pop- opy coverage, density of invasive species, density of F. granlar), Quercus alba (white oak), Carya spp. (hickories), Toxicodendron radicans (poison ivy), Acer saccharum (sugar difolia, and density of C. caroliniana were measured, and maple), Carpinus caroliniana (American hornbeam), and soil samples were collected. Sunlight was measured in lux Liquidambar styraciflua (sweetgum) (Ettman 1980). Spe- using a digital light meter. A relative light value was calcucies that are less common and indicate a post-climax forest lated by converting the light measurement at each distance are Asarum spp. (wild ginger), Polystichum acrostichoides interval to a proportion of the light measurement at the or(Christmas fern), Sanguinaria canadensis (bloodroot), and igin. Data collection for light was not consistent because it Panax quinquefolius (American ginseng) (Ettman 1980, was measured on different days and at different times of day depending on the site. Canopy coverage was measured usCarl Brown, personal communication). One area known to contain the ideal conditions for ing a densiometer. This measurement was taken facing four S. glabra is Lullwater Preserve by Emory University in At- directions and averaged. Density of invasive species, F. granlanta, Georgia. Emory’s Department of Environmental Sci- difolia, and C. caroliniana were measured on a scale of zero ences and the Wesley Woods Hospital horticultural therapy to five, with zero meaning none present and five meaning program have joined forces to preserve this threatened spe- abundant. F. grandifolia and C. caroliniana trees were not cies (Williams 2012). Patches of S. glabra found at these sites counted twice if an individual was situated between two inare monitored, and its cultivation is strictly regulated (Wil- tervals. For the soil sampling, about two cups of soil were collected using a trowel and liams 2012). Cultivation is perplaced in a small plastic bag. mitted in order to collect plant Soil samples were transstarts propagated from wild S. “Efforts to conserve S. glabra and ported to the lab and a portion glabra runners (Williams 2014). to restore its habitat would allow us of soil was massed on paper towCultivated S. glabra individuals to tap into its unexplored medical els. The soil was left in the lab to have yet to be reintroduced to properties” dry and was massed a second Lullwater or other forests betime after a period of four days. cause the plant grows slowly and The percent difference between is fragile in its early stages of life. This study focused on identifying suitable ecolog- the initial and final masses was calculated and used as the ical conditions for S. glabra in the Emory University area. measurement of soil moisture. A portion of the remaining We identified the effects of (1) density of the invasive species soil was added to a cup of water with a soil to water ratio of H. helix and Ligustrum sinense (Chinese privet), (2) tree 1:6. The pH of a neutral solution was measured for calibracanopy density, (3) sunlight intensity, (4) soil pH, (5) slope tion, and the pH of the soil-water slurry was measured and recorded.

ECOLOGY

Kyra C. Wu

Data Analyses Scatterplots were created using data from the parallel and uphill transects, with distance from the origin on the x-axis and the ecological variable on the y-axis. To achieve normal distribution, data for canopy density and light were converted to log(x+1) data. Linear regression R2 values and p-values were calculated. If the data for a variable failed the Shapiro test in the log-converted form, the form of the data that produced the more normalized histogram was used for linear regression calculations.

Results

Of the eight ecological factors that were expected to influence the presence of S. glabra, one factor varied significantly along the transects, two showed potential trends, and the remaining five did not significantly differ along the transects. Canopy density increased as distance from the origin increased (Linear regression, R2 = 0.177, P = 0.004). Parallel and uphill transect trendlines and standard errors notably overlapped for the canopy density variable (Figure 1a). The soil pH variable was not significant along the transects (Linear regression, P = 0.090), but there was a potential trend (Figure 1b). Another potential trend was observed in the F. grandifolia density variable, where F. grandifolia density increased as distance from the origin increased (Figure 1c). However, as with the soil pH, F. grandifolia density was not statistically different along the transects (Linear regression, P = 0.063). We observed that F. grandifolia density depended on the site, as some sites contained a large quantity of F. grandifolia trees and others contained none.

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The remaining six ecological factors did not significantly change as the distance from S. glabra increased. C. caroliniana density showed a slight negative correlation along the parallel transect in Figure 1d, but no trend was observed along the uphill transect (Linear regression, P > 0.1). In the sites that were sampled, C. caroliniana was either abundant or absent. The log value of light relative to the origin remained around zero (Figure 1e), and the trend was not statistically significant (Linear regression, P > 0.1). The soil moisture remained around 13% saturation (Figure 1f) and did not vary along either transect (Linear regression, P > 0.1). Similar to C. caroliniana, invasive species were either abundant or completely absent, depending on the site (Figure 1g). Due to this variation, there was not a consistent trend along the transects (Linear regression, P > 0.1). Slope remained around -20 degrees, but as distance from S. glabra increased, slope increased on parallel transects and decreased on uphill transects (Figure 1h). There was not a consistent or significant difference in slope along the transects (Linear regression, P > 0.1). However, the slope was non-zero along both transects (Figure 1h)

Discussion

The objective of our study was to determine the ecological factors that influence the presence of S. glabra and explore the conditions of its ideal habitat. We looked for a gradient along transects as the distance from S. glabra increased. Factors were chosen based on previous research and general observations about the sites. Although several variables exhibited a trend, only canopy density changed sig-

ECOLOGY

Figure 1: Gradients of ecological factors that influence S. glabra presence along transects directed parallel to the hill and uphill. Data for each of the ecological variables were collected at five-meter intervals along a 20-meter parallel transect and uphill transect, with the origin in the center of a S. glabra patch. Uphill transect data is represented by red and parallel transect data is represented by green. Lines of best fit and 95% confidence intervals were added, and linear regression analyses were performed. Canopy density was statistically higher as distance from the S. glabra patch increased, and the slope of the ground was non-zero. All other trends were not statistically significant.

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nificantly as distance varied. The data support our hypoth- difolia data could potentially support our hypothesis that F. esis that canopy density increases as distance from S. glabra grandifolia increases as distance from the origin increases. increases, as well as Brown’s research that S. glabra thrives in Density of C. caroliniana did not differ along the tree gaps and coves (Carl Brown, personal communication). transects. Although Ettman (1980) suggests that C. caroLarge beech trees frequently cause the tree gaps and enable liniana is the most frequent in the shrub and sapling class, S. glabra to grow higher along the limbs of small understory our data shows an absence of individuals in several sites, trees and shrubs as it receives more sunlight (Ettman 1980, similar to the F. grandifolia data, indicated by many zeros Carl Brown, personal communication). During our data in the data. As with F. grandifolia variation, the observed collection, we observed a large fallen beech tree ourselves trend may be due to close proximity to anthropogenic disin one of the S. glabra sites, suggesting a confirmation of turbance, as several sites were not far from walking paths. Ettman and Brown’s studies. Additionally, the data may not be significant because C. car While soil pH data did not produce a significant oliniana does not have as critical of a role as F. grandifolia trend, the data still revealed a surprising result: the soil near does in the forest ecology (i.e. C. caroliniana does not cause the S. glabra site is slightly less tree gaps). acidic than the soil surround The data for light relative ing the site. Soil in forests of the to the origin did not support our As an indicator of a rare, fragile Southeast typically has a low hypothesis, as we expected light habitat, S. glabra must be at the pH, but many plants can grow to decrease as distance from the forefront of conservation research in a wide range of pH levels. origin increased. Also, we expectin the southeastern United States. Thus, S. glabra’s potential prefed to see a simultaneous increase erence for alkaline soils might in canopy density and decrease in be explained by the other spelight along the transect because cies that grow in old-growth oak-hickory forests. Davis and the two are inevitably correlated. One explanation for the Pearsons (2014) found that the leaves of Liriodendron tulip- lack of light variation is that the light meter was not caliifera (tulip poplar) and Acer saccharum (sugar maple), spe- brated to an open sunlight reading before measurements, cies that are abundant in Lullwater Preserve, contain high thereby inhibiting a full comparison of light along the tranlevels of calcium, a base-forming chemical that increases the sects. The trend could be explained by the impact of the pH of soil. When L. tulipifera and A. saccharum leaves drop, sun’s movement as well. Data collection was executed over calcium is released into the soil (Davis and Pearsons 2014). several hours, and the daylight available to S. glabra varied S. glabra tends to grow with these calcium-rich species, and with every measurement. therefore, the soil around S. glabra patches is less acidic. Percent soil moisture supported our hypothesis Other native species, such as Panax quinquefolius (Amer- and remained relatively constant across all transects. As S. ican ginseng) and Hybanthus concolor (green violet), are glabra tends to grow in mesic forests, we did not expect to indicators of alkaline soil and frequently grow with S. glabra see a large degree of soil saturation (Ettman 1980). Con(David and Pearsons 2014, Ettman 1980). stant soil moisture along the transects indicates that water As previously mentioned in the explanation of can- was not pooled anywhere parallel to or up the hill. The lack opy density, F. grandifolia grows with S. glabra until the area of pooled water is due to the tendency of S. glabra to grow is perturbed and F. grandifolia falls to create a tree gap. Al- on slopes, specifically north-facing slopes, which allows for though the data was not significant for F. grandifolia density consistent drainage (Ettman 1980). in the S. glabra sites, Ettman (1980) claimed that the pres- The absence of an invasive species trend contradicts ence of F. grandifolia was twice as dense and frequent in the our hypothesis that invasive species would increase as disEmory University area compared to trees such as L. tulipif- tance from S. glabra increases. Chafin (2008) claims that inera and Q. alba. Additionally, the tree’s presence indicates an vasive species threaten S. glabra growth; therefore, we would old-growth forest and a post-climax community, the perfect expect invasive species to be less abundant in areas with S. community for S. glabra (Ettman, 1980). Our data showed glabra. As with the F. grandifolia and C. caroliniana data, a cluster of data points near zero, indicating that in a few several sites lacked invasive species entirely. Lullwater Presites, F. grandifolia was completely absent. Although S. gla- serve is owned and maintained by Emory University, which bra prefers tree gaps, canopy density significantly increased regularly removes harmful invasive species from the nature along the transects across all sites, showing that trees other preserve. The sites without invasive species were likely areas than F. grandifolia became more abundant along the tran- that witnessed invasive species removal efforts. sect in those particular sites. The sites lacking F. grandifo- The slope of S. glabra sites remained around -20 delia might have been located near an anthropogenic distur- grees, with some sites reaching over -40 degrees. While the bance, such as walking paths or cleared areas, which could slope of the hill did not change significantly as the distance have disturbed F. grandifolia growth. However, the F. gran- from S. glabra changed, the slope was non-zero for all sites

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References:

Chafin, L. G. 2008. Bay Star-vine Fact Sheet. Georgia Department of Natural Resources, Wildlife Resources Division. Davis, J. and W.S. Pearsons. 2014. Growing and Marketing Ginseng, Goldenseal, and Other Woodland Medicinals. New Society Publishers, Gabriola Island, Canada. Ettman, D. 1980. A Study of Schisandra glabra (Brickell) Rehder, a Rare Species Endemic to the Southeastern United States. Thesis, Emory University, Atlanta, Georgia, USA. Fan, J.-H., L. B. Thien, and Y.-B. Luo. 2011. Pollination systems, biogeography, and divergence times of three allopatric species of Schisandra in North America, China, and Japan. Journal of Systematics and Evolution 49:330–338. Lyles, J. T., P. Tyler, E. J. Bradbury, K. Nelson, C. F. Brown, S. T. Pierce, and C. L. Quave. 2017. Comparative Phytochemical Analysis of Chinese and Bay S. glabra (Schisandra spp.): Potential for Development as a New Dietary Supplement Ingredient. J Diet Suppl 14:640-652. Panero, J. L., and P. D. Aranda. 1998. The Family Schisandraceae: A New Record for the Flora of Mexico. Brittonia 50:87–90. Panossian, A., and G. Wikman. 2008. Pharmacology of Schisandra chinensis Bail.: an overview of Russian research and uses in medicine. J Ethnopharmacol 118:183-212. Szopa, A., M. Barnaś, and H. J. P. R. Ekiert. 2018. Phytochemical studies and biological activity of three Chinese Schisandra species (Schisandra sphenanthera, Schisandra henryi and Schisandra rubriflora): current findings and future applications. United States Department of Agriculture (USDA). 2018. Threatened and endangered plants database. United States Department of Agriculture. Valente, M.J. 2007. Clonality and Genetic Diversity Revealed by AFLPs in Schisandra glabra (Brickell) Rheder (Schisandraceae), a Rare Basal Angiosperm. University of Tennessee, Knoxville, Knoxville, Tennessee. Williams, K. 2012. Saving the S. glabra. Emory News Center. Emory University.

Annie Schiffer is a junior in the college studying biology and environmental sciences. She is passionate about ecology, and she plans to pursue a PhD in biology after she graduates. Outside of her classes, she works in the Brosi Lab studying plant-pollinator interactions and enjoys fieldwork during the summer.

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at every distance interval, which supports our hypothesis. Our data confirms the Ettman (1980) study and Brown’s observations that S. glabra prefers slopes near streams (Carl Brown, personal communication). As mentioned in the soil moisture discussion, the slope trend is correlated with the soil moisture trend, causing significant water drainage across the transects. This study highlights which environmental conditions are critical for S. glabra health, and which ones are less influential for its survival. More specifically, we demonstrate that S. glabra thrives in the tree gaps of coves possibly composed of F. grandifolia and situated on hills with slightly less acidic soil. An exploration of the ecological factors determining S. glabra presence is critical for preserving oldgrowth forests and their associated native species. S. glabra is one of many native species that are threatened by human disturbance, habitat loss, and competition from other species. As an indicator of a rare, fragile habitat, S. glabra must be at the forefront of conservation research in the southeastern United States. A major aspect of conservation research is expanding a species’ range, and our research provides ecological information for the reintroduction of S. glabra into its ideal habitat. Additionally, S. glabra’s connection to S. chinensis indicates potential medicinal properties that could be utilized in a world of growing antibiotic resistance. From an ethnobotanical and ecological standpoint, the habitat of S. glabra could hold powerful botanical information and should be preserved for future generations.

How does a Patientâ&#x20AC;&#x2122;s Occupational Status Influence a Doctor-Patient Relationship and the Satisfaction Rates of Overall Health Care Systems like the NHS? Kyla Wickens iStockphoto

Introduction and Research Question

SOCIOLOGY

General practitioners alone have some of the strongest effects of patient satisfaction on health care since they are often the first point of contact for patients in need of medical services. These health care professionals additionally exemplify an important indicator for the level of health care services, as these professionals help shape the patients’ perceptions of their overall health care experience. The general practitioners’ role on shaping patients’ impressions is important as satisfaction with basic medical services symbolizes an important aspect of living standards, and further highlights the issue of equity with access and health outcomes. While there is extensive research on how a doctor’s behaviors and status influences their relationships with patients, there is a lack of research that focuses on how the behaviors and statuses of patients’ shape those equivalent relationships. General practitioners regularly interact with patients of different ages, races and socioeconomic statuses. However, not all general practitioners treat their patients equally. Past research illustrates a common shift in a health care professional’s behavior with patients who come from less affluent and potentially more stressful backgrounds than those who are more wealthy. While there are multiple factors that influence health outcomes, would these relationships change if the less affluent obtained a role with improved working conditions and economic benefits? This further motivated the development of this current research study, which asks: how do patients’ occupational statuses influence a doctor-patient relationship and the satisfaction rates of overall health care systems like the NHS? This is important as there is a lack of research that focuses on how patients’ job rankings specifically help influence positive or negative relationships with their doctors. In addition, there is a lack of evidence that portrays how these varying occupational statuses further influence patients’ impressions of their overall health care system. This current paper will initially pass through a broad literature review that addresses theories that explain the influences of occupation on doctor-patient relationships and overall impressions. A detailed methods section follows afterwards and is then trailed by a results section, which is further complimented with a discussion and conclusion on the limitations, future directions and the importance of these relationships. Moreover, this paper aims to highlight how occupation plays a significant role in influencing a doctor-patient relationship and the overall satisfaction rates of the NHS.

Theory and Background

Social interaction between a patient and a general practitioner is crucial to satisfaction rates, as these relations help form and define the connection between a doctor and patient. This links to Speedling and Rose’s (1985) use of

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the social interaction theory, where the establishment and upholding of a doctor-patient relationship is constantly maintained through hard work of effective and satisfying interactions, which may also include times of conflict and compromise. While doctors attempt to provide the basic needs of care to almost everyone, some patients like those who come from more stressful and challenging backgrounds have a harder time maintaining positive relations with their doctors. Individuals who come from lower social classes with low-level positions face difficulty in maintaining a positive relationship with their doctor, as they are provided with less positive socio-emotional statements, information giving, directions, and opportunities for socio-emotional partnership building (Willems et al. 2005). This is an issue, as patients from higher social classes with more affluent occupations are able to actively communicate and show more affective expressiveness to their doctors. These interactions between doctors and individuals from different statuses are significant as they show that the more wealthy patients are provided with more information and effort on their healthcare. Moreover, this reveals that those who obtain higher statuses have a more satisfying interactions and positive relationships with their doctor. This is a common finding in other past research, as the less affluent patients report less favorable assessments with their doctors specialized in primary care. According to Campbell, Ramsay and Green (2001), these low-status patients in particular feel that their doctor is unable and unwilling to recommend them to the appropriate types of services. This is an issue as these unsatisfactory interactions between doctors and the less affluent individuals, further determent the opportunity to build positive relationships. Moreover, these interactions negatively impact their satisfaction rates with their doctors, as they feel like they are not given the respect and time they need. Respect and time are some of the most important actions and expectations patients have of doctors, and if those expectations are not met, their positive impressions decline along with their doctor-patient relationship (Weston, 1996). Even though some doctors influence a more negative relationship with their patient through their shifts in behavior, patients’ behavior equivalently impacts the development and maintenance of these doctor-patient relationships. Past research presses on the point that stressful working conditions combined with sorrow are some of the most common psychosocial problems amongst individuals (Gulbrandsen, Hjortdahl and Fugelli 1997). This is important as it emphasizes how both poor and stressful conditions can influence the onset and persistency of negative behaviors within a patient, which can be further presented during an interactive meeting with a doctor. Even though both the doctor and patient’s behaviors similarly influence their relationship, this further reveals that occupational status is a variable that can both mediate and impact the impressions

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SOCIOLOGY

and interactions of their doctor-patient relationship. Since tions like the elderly and the poor who come from challenggeneral practitioners represent a large component of an ing circumstances however, have more negative impressions overall health care system, can patients’ occupational status- on their healthcare system, as they are the ones that use and es further impact the satisfaction rates of their overall health need the most medical care (Bodenheimer & Grumbach care system (NHS)? 2016). This is important as the experience of such popula This addresses the idea of institutional theory, which tions within the system is crucial for their overall evaluation argues that the public support for health care systems is as a health care system. shaped by the institutional design of those systems (Wendt, Overall, the social interaction theory is important Kohl, Mischke and Pfeifer 2009). as it highlights how a patient’s Higher levels of satisfaction are occupational status can impact commonly found in countries the interactive relationship be“While doctors attempt to provide that have both higher healthcare tween a doctor and patient. The the basic needs of care to almost spending and higher public ininstitutional theory additionaleveryone, some patients like those volvement within their health ly illustrates how patients with who come from more stressful and care system. While these factors different backgrounds and occhallenging backgrounds have a help mold the satisfaction rates cupations orient their behavior of patients, medical professionaround institutional arrangeharder time maintaining positive als remain to be one of the cenments, especially those pertainrelations with their doctors.” tral roles of healthcare provision ing to general practitioners. Furwho influence the patients overthermore, these orientations, all experiences within a meddeveloping behaviors and expeical setting (Speedling and Rose 1985). This is significant riences with their doctors further impact their satisfaction as doctors are commonly the first and sometimes the only rates of their overall health care system. Previous research point of contact patients have with any part of their health and the following theories further motivated the hypothesis care system. The larger presence and availability of general of this current study: if patients obtain a lower-ranked ocpractitioners influences not only an increase in satisfaction, cupation, then that person is (1) less likely to have a positive but more frequent visits to the doctor. This is common as relationship with their general practitioner and (2) has lowless-satisfied patients tend to visit the doctor less regularly er satisfaction rates with their overall health care system. (Mirowsky and Ross 1983). With regards to the institutional Methods theory, this further reveals how patients orient themselves This current study was administered through the at specific institutional arrangements (e.g. general practi- use of surveys. These surveys contained basic demographic tioners), and that their overall attitudes and impressions are questions that asked about factors such as: age, gender, ocformed through these processes of coordination and interaction. Through these connections and orientations, general cupation, education, race, marital status and political party practitioners with an established role in health care system affiliation. In addition, these surveys had questions that fohave the power to influence their patients’ experiences and cused on the individual’s personal experience with specifattitudes on their overall health care system. Furthermore, ic components of the NHS, such as: satisfaction with GP, these institutions matter especially with regards to satisfac- surgery, waiting time, and decision making. In addition, the tion, as positive evaluations of overall health care services survey had more broad questions that assessed an individustem from these interactive doctor-patient relationships. al’s overall health, their general satisfaction with the NHS as Most importantly, strengthening doctor-patient relation- a system, and how the NHS would benefit from changes like ships can be a potential clue in increasing overall levels of Brexit or increased privatized care. Lastly, the survey had satisfaction, which can be crucial for the legitimacy of health two additional interview questions available for those who care systems in the future (Wendt, Kohl, Mischke and Pfeif- wanted to incorporate a more in depth opinion on both the NHS and the US health care system. This particular mether 2010). Despite the influences of financial support, patients’ od is beneficial to this current study, as it not only retrieves involvement, and high density of general practitioners that personal information, but it is an easy tactic to administer; mediate the relation between healthcare personnel and sat- it contains both quantitative and qualitative approaches, it is isfaction, these overall satisfaction rates differ substantial- a cost-effective measure, and it can gather information from ly from groups of different social classes, occupations and multiple people in a short amount of time. The current study was based off a convenient samthose with fewer direct contacts (Speedling and Rose 1985). ple, as it was difficult to conduct a purely randomized samPatients who come from wealthier backgrounds are comple in a short amount of time. The sample consisted of 451 monly more satisfied with their overall health care system than those with less affluent backgrounds. Other popula- participants, as 49.1% of the sample was male while the remaining 50.9% was female. The present sex differences

SOCIOLOGY

portrays an almost equal divide of genders. Despite survey efforts in order to obtain equal variation in age, our sample was leaning more towards the younger end of the spectrum (e.g. 20-35 years old). Each individual was paired with another researcher and were each was assigned to conduct 30 surveys. Each pair ventured to the location of their choice in order to administer and complete these surveys. Initially, the surveys took a long time to complete as we conducted them by talking to one person at a time. In order to simplify and accelerate the data collection process, my partners and I approached groups of 3-4 in populated areas such as Finsbury Park, the Kensington Gardens and Notting Hill. Even though we had the advantage of reading the written survey questions off the papers, we still introduced them as open-ended questions. This was important and beneficial as the participants were able to provide more information on these survey questions, which turned into additional field notes. For my independent variable, I measured “occupational status” through the occupation question on the survey, which listed various categories of professional statuses (e.g. self-employed, higher managerial). As for my dependent variables, I measured “doctor-patient relationships” through the GP satisfaction scale, which rated from one (very unsatisfied) to five (very satisfied). In addition, I measured “overall NHS satisfaction” with the overall NHS satisfaction rates which scaled from one (poor) to five (excellent). Fortunately, none of these variables needed to be recoded, but they did need to be relabeled within SPSS for clarity. The data analysis of this current study was administered through the Statistical Package for the Social Science (SPSS) program. For the univariate analysis, I conducted a frequency procedure on the following variables: GP Satisfaction Rates, Overall NHS Satisfaction Rates, and Occupation. In addition, I supplemented the univariate analysis with bar graphs for each variable, in order to visualize the variability. In addition, I conducted a crosstabs procedure and some chi-square tests with these variables for the bivariate analysis. The crosstabs procedure reveals the relationship between multiple variables, and the chi square tests highlights the significance of those relationships. The current study’s set p-value is less than or equal (0.05), which means any value under or including .05 is statistically significant. Although, p-values that are between (0.05) and (0.10) are not disregarded, as those values approach significance.

Results

Univariate Analysis As seen below in (Table 1), there is a count for how many participants completed or opted out of a particular part of the survey. For the independent variable, “occupation”, only ten participants had missing data from this part of survey. As for the dependent variables, all participants completed the GP satisfaction ratings, while only one par-

20 | Emory Undergraduate Research Journal

ticipant did not complete the overall NHS satisfaction rating scale. Around 44.6% of all participants reported to be “quite satisfied” with their general practitioner as seen in (Table 2). In addition, only 3.1% of the sample reported to be “very dissatisfied” with their local doctor. As for overall NHS satisfaction rates, 49.2% of the sample reported to be equivalently “quite satisfied” with their overall NHS system. Although, as seen in (Table 4), only 4.2% reported to be “very dissatisfied” with the NHS system as a whole. Lastly as mentioned in (Table 3), around 30.2% of the sample had an intermediate managerial position, 23.7% were students and only 2.4% of the sample never worked. See Tables 1-4 and Bar Graphs 1-3 for further breakdowns of each variable. Bivariate Analysis The following data within (Table 6) further reveals the relationship between occupational status and GP satisfaction rates. The chi-square test of this association present a p-value of 0.027 (see Table 7 for further reference). The presented data supports the first part of the hypothesis that occupational status influences GP satisfaction rates, as those with less affluent occupations report lower levels of satisfaction to their doctor than those who held wealthier positions. For example, around 4.2% of those who obtained a semi-routine service occupation, reported to be “very satisfied” with their general practitioner, while 14.4% of the participants who were self-employed and 32.2% of those who had intermediate managerial positions similarly reported to be “very satisfied” with their local doctor. This is not always the case as participants with both affluent and lower ranked occupations report equivalent rates of dissatisfaction against their general practitioners. For example, as seen in (Table 6), both 30.8% of participants who had higher managerial positions and those who were self-employed reported to be “very dissatisfied” with their doctor. See (Table 6) for further references and debriefing. The data presented within (Table 8) portrays the relationship between occupational status and overall NHS satisfaction rates. The chi-square tests present a p-value of 0.279, as seen in (Table 9). The following data does not support the second part of the hypothesis that occupation influences overall NHS satisfaction rates, as participants that occupy less-affluent positions are more satisfied with the overall NHS system that those who hold the highest working positions. For example, 32.4% of participants who are employed with intermediate managerial positions reported to be “very satisfied” with the NHS system, while only 11.4% of those with higher managerial positions reported similar ratings. Despite these differences of satisfaction across different occupations, some of the lower ranked occupations have few differences in dissatisfaction on the NHS system as a whole. For instance, 17.6% of participants who obtained both skilled craft and self-employed positions similarly reported to be “very dissatisfied” with the overall NHS system.

Table 1: Overall Frequency Statistics GP Satisfaction Occupation Updated

Overall NHS Satisfaction Updated

Valid

451

441

450

Missing

Mean

3.8137

5.7460

3.7844

Median

4.0000

7.0000

4.0000

Table 2: Frequencies of GP Satisfaction Frequency Percent Valid Percent Cumulative Percent Valid Very Dissatisfied

3.1

Quite Dissatisfied

9.3

12.4

Neither

16.9

29.3

Quite Satisfied

201

44.6

73.8

Very Satisfied

118

26.2

100.0

Total

451

100.0

SOCIOLOGY

Table 3: Frequencies of Occupation (Updated) Valid

Missing

Frequency

Percent Valid Percent

Cumulative Percent

Never Worked

2.4

2.5

Student

107

23.7

24.3

26.8

Routine Service

3.5

3.6

30.4

Semi-Routine Service

4.4

4.5

34.9

Skilled Craft

4.4

4.5

39.5

Self-Employed

9.3

9.5

49.0

Lower Managerial

6.7

6.8

55.8

Intermediate Managerial

136

30.2

30.8

86.6

Higher Managerial

13.1

13.4

100.0

Total

441

97.8

100.0

System

2.2

451

100.0

Total

Table 4: Frequencies of Overall NHS Satisfaction (Updated) Frequency Percent Valid Percent Cumulative Percent Valid

Very Dissatisfied

4.2

Quite Dissatisfied 41

9.1

13.3

Neither

14.0

27.3

Quite Satisfied

222

49.2

49.3

76.7

Very Satisfied

105

23.3

100.0

Total

100.0

450

99.8

Missing System

0.2

Total

451

100.0

Table 5: Crosstabs Case Processing Summary Valid

Cases Missing Percent

Total

Percent N

Percent

Overall NHS Satisfaction Updated * Occupation Updated

440

97.6%

11 2.4%

451 100%

GP Satisfaction * Occupation Updated

441

97.8%

10 22.%

451 100%

Volume XV, Spring 2019 | 21

Table 6: Crosstabs of GP Satisfaction * Occupation Updated Never Worked

Student

Routine SemiService Routine Service

Skilled Craft

SelfLower Intermediate Higher Total Employed Managerial Managerial Managerial

15.4 1

7.7

7.7 0

30.8

7.7

100

Quite Dissatisfied 1

2.4

17.1 2

4.9 1

2.4

7.3 1

2.4

14.6

26.8

100

Neither

2.7

5.3

2.7 3

5.3

38.7

13.3

100

Quite Satisfied

25.3 10

5.2 10 5.2

10 5.2 17

8.8

7.7

27.8

13.9

194 100

Very Satisfied

3.4

27.1 0

14.4

4.2

32.2

10.2

118 100

Total

11 2.5

9.5

6.8

136 30.8

13.4

441 100

GP Satisfaction (missing = 10) Very Dissatisfied

107 24.3 16

4 5

4.2

3.6 20 4.5

4.2 17

20 4.5 42

Table 7: Chi-Square Test - GP Satisfaction * Occupation Updated Value

Asymptotic Significance (2-sided)

Pearson Chi-Square

49.058

0.027*

Likelihood Ratio

49.323

0.026

Linear-by-Linear Association

1.069

0.301

N of Valid Cases

441

Table 8: Crosstabs of Overall NHS Satisfaction Updated * Occupation Updated Never Student Worked

Routine Service

SemiRoutine Service

Skilled Craft

SelfLower Intermediate Higher Employed Managerial Managerial Managerial

Total

Very Dissatisfied

5.9

17.6

Quite Dissatisfied

2.5

22.5 2

2.5

Neither

1.6

22.6 4

6.5

Quite Satisfied

2.8

28.2 6

2.8

Very Satisfied

2.9

21.9 3

2.9

Total

11 2.5

17.6 3

17.6

29.4

11.8

100

2.5

100

3.2

6.5

12.9

4.8

12.9

100

4.2

3.7

14 6.5

16 7.4

29 13.4

216 100

4.8

2.9

15 14.3

32.4

12 11.4

105 100

42 9.5

30 6.8

136 30.9

59 13.4

440 100

Overall NHS Satisfaction Updated (missing = 11)

107 24.3 16 3.6

20 4.5

19 4.3

6.7

Table 9: Chi-Square Test â&#x20AC;&#x201C; Overall NHS Satisfaction Updated * Occupation Updated Value

Asymptotic Significance (2-sided)

Pearson Chi-Square

36.198

0.279

Likelihood Ratio

35.584

0.303

0.517

Linear-by-Linear Association 0.419 N of Valid Cases

440

22 | Emory Undergraduate Research Journal

See (Table 8) for further analyses of the collected data.

Bar Graph 1: Frequencies of GP Satisfaction

Discussion and Conclusions

Bar Graph 2: Frequencies of Occupation (Updated)

tem because they expect less Bar Graph 3: Frequencies of Overall NHS Satisfaction (Updated)

of the overall healthcare structure than from their general practitioner. This is important as this creates a greater emphasis on the need to improve the communication between doctors and all types of patients. Moreover, this improvement can further lead to the sustainability of trust and happiness in patients. Other potential confounding factors that can similarly influence the satisfaction rates of patients on their overall healthcare system, are the social determinants of health, (e.g. education, income inequality) (Dr. Bledsoe

Volume XV, Spring 2019 | 23

SOCIOLOGY

These results support the first part of the hypothesis as there is a significant relationship between occupational status and the general practitioner satisfaction rates. This reflects similar findings in previous research as those from lower occupational statuses are more disadvantaged not only because of their circumstances and poorer health, but because of the doctor’s misperception of their desire and need for information and the ability to take part in the care process (Willems et al. 2005). This current study adds on to other research as it further highlights that there might be poor communication that exists between doctors and patients from low-class statuses. Around 22.6-44.9% of patients in different health care systems report having communication issues with their local doctor and 7.7-21.1% of those patients additionally face difficulty in comprehending instructions or responses from health care professionals (Cleary et al. 1991). This is important as the communication problems touch on the prevalent health illiteracy within patients and the inconsistencies found within the roles of a doctor. Furthermore, more efforts should be made to develop teaching methods, which encourage and focus on establishing effective communication between doctors and patients from lower occupational statuses. The data of this current study did not support the second part of the hypothesis as there is no significant relationship between occupational status and overall NHS satisfaction rates. Despite the insignificance, this finding is important to highlight, as it shows how patient satisfaction rates are mutually exclusive to components of the health care system, and does not necessarily influence the overall healthcare satisfaction rates. A past UK study addresses the mutual exclusivity as overall healthcare satisfaction rates tend to be rated higher than satisfaction rates with specific parts of the doctor’s service (Carlsen and Aakvik 2006). This reflects a previous point, where most patients only encounter with the medical services is through their interactions with their doctor, so this is sometimes the closest patients come to assessing their “overall” health care. With that, there are multiple components and expectations a doctor needs to meet that further influence patients’ overall impressions of their healthcare. For instance, doctors who allow the opportunity for patients to partake in shared decisions about health care and treatment, have more satisfied patients than doctors who independently make decisions on services and treatment (Carlsen and Aakvik 2006; Speedling and Rose 1985). In addition, other factors that might affect the doctor-patient relationship is the physician’s ability to engage on an interpersonal and emotional level with their patients, without disregarding their present complaints (Speedling and Rose 1985; Rosenthal 2003). Patients who have a low-ranked occupation might give higher levels of satisfaction to their overall health care sys-

SOCIOLOGY

July 2018). Past research found that patients who were less educated and came from less affluent backgrounds saw that their doctors’ expectations were less met (Willems et al. 2005). This is important as it shows how interventions in improving both communication with patients and the participation of patients with low education influence enhancements in health outcomes. Even though occupational status has an impact on the patients impressions of their doctors, there are other significant factors that influence these attitudes on doctors and overall healthcare institutions, which are difficult to control and measure. The convenient sample of this current study is a limitation as this sample was limited to particular locations in London such as large parks. This is important to highlight as this small sample is not representative of the United Kingdom and the data was collected and analyzed in a short period of time. With regards to this particular study, some of the limitations stemmed from the survey, as there were few qualitative questions that address and provide additional information on the more in depth personal experiences and varying backgrounds of these participants. In addition, this survey is limiting to this particular study as it only collects data from patients and not doctors. Furthermore, there is only the patients’ single perspectives that are analyzed within the data. In order to have a greater understanding of the interactions that take place within existing doctor-patient relationships, there should be more qualitative research that accounts for both the patient and doctor’s perspectives. This is beneficial as this would help future research on finding methods in improving communication between doctors and patients, such as increasing a doctors’ awareness of the contextual communicative differences and empowering patients to express their concerns and preferences. The encouragement for the onset and development of these future studies can lead to potential improvements in health literacy, participation and satisfaction rates within patients. There is a lack of research that focuses on how factors like occu-

pational status directly influences the impressions patients have on their doctors and their overall health care systems. Moreover, this current study motivates future research on how particular factors like income inequality, jobs, education and race influence the attitudes of patients within a medical setting.

References

Bledsoe, Ashlee. 2018. “Social Determinants of Health: Income Inequality, Education, Race/Ethnicity.” Powerpoint presented at University College of London. July 2, London, United Kingdom. Bodenheimer, Thomas & Grumbach, Kevin. 2016. “Access to Health Care.” in Understanding Health Policy: A Clinical Approach McGraw-Hill Medical. Campbell, J., Ramsay J., and Green J. 2001. “Age, gender, socioeconomic, and ethnic differences in patients’ assessments of primary health care.” Quality in Health Care 10:90-95. Carlsen, Benedicte and Aakvik, Arild. 2006. “Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction.” Health Expectations 9:148-57. Cleary, P., Edgman-Levitan, S., Roberts, M., Moloney, T., McMullen, W., Walker, J. and Delbanco, T. 1991. “Patients Evaluate Their Hospital Care: A National Survey.” Health Affairs:254-67. Gulbrandsen, Pål, Hjortdahl, Per, and Fugelli, Per. 1997. “General Practitioners’ Knowledge of Their Patients’ Psychosocial Problems: Multi-practice Questionnaire Survey.” British Medical Journal 314(7086):1014-18. Mirowsky, John and Ross, Catherine. 1983. “Patient Satisfaction and Visiting The Doctor: A Self-Regulating System.” Social Science and Medicine 17(18):1353-61. Rosenthal, Marsha. 2003. “Disappointed Expectations and Disrupted Trust: The Patient’s Experience of Problems with Health Care.” Pp. 47: Brown University. Speedling, Edward and Rose, David. 1985. “Building an Effective Doctor-Patient Relationship: From Patient Satisfaction to Patient Participation.” Social Science and Medicine 21(2):115-20. Wendt, Claus; Kohl, Jurgen; Mischke, Monika and Pfeifer, Michaela 2009. “How Do Europeans Perceive Their Health Care System? Patterns of Satisfaction and Preference for State Involvement in the Field of Healthcare.” European Sociological Review 26(2):177-92. Weston, Ruth. 1996. “How Satisfied are Parents with their Doctor?” Australian Institute of Family Studies 43:22-23. Willems, S., Maesschalck, S., Deveugele, M., Derese A. and Maeseneer, J. 2005. “Socio-economic status of the patient and doctor-patient communication: does it make a difference?” Elsevier 56:139-46.

My name is Kyla Wickens and I am a fourth-year double majoring in psychology and sociology. I am currently working in Dr. Sherryl Goodman’s Child and Mother’s Emotions Lab (CAMEL) at Emory University. This research study was done during Emory’s Sociology Comparative Health Care Systems study abroad program in the UK in 2018. Some of my other sociology research was presented at the SEUSS Conference in 2018. My future goal is to give back to my community by combining my love for visual arts and my interests in psychology and open up a clinical art therapy center.

24 | Emory Undergraduate Research Journal

Special Feature: Dr. Sarah Fankhauser By Camilla Li

As a woman in STEM herself who has mentored aspiring women in STEM, Dr. Fankhauser has seen firsthand the importance of having female role models in science and technology. The story of Ada Lovelace, as told in Ada and the Engine, highlights the challenges that women have faced historically in pursuing STEM careers, and provides a heroine in Ada as she relentlessly pursues what she loves. To some extent, Dr. Fankhauser’s own research has influenced her involvement in the Atlanta Science Festival. Though her research is focused primarily on two completely different areas, there is a prevailing theme of community. One project focuses on bacterial communities in agriculture by investigating how different farming techniques can impact soil microbiomes and soil health. Her other main research project focuses on the scientific community and the value of scientific publishing in helping middle and high school students identify as scientists in a larger scholarly community. The idea is that contrary to some misconceptions, science is a

collaborative effort. Likewise, the Ada Project emphasizes the importance of community in both appreciating science and inspiring others with science. In addition, Dr. Fankhauser has studied the pathogenesis of Burkholderia cenocepacia, a bacterium that has shown a high antibiotic resistance and can severely compromise the health of patients with chronic lung diseases. The goal of the research was to identify as many virulence factors as possible. She believes that the future of treating antibiotic-resistant strains of bacteria may involve using more targeted antibiotics that go to the right place in the body, going out into remote environments to look for new antibiotics, and/or combining multiple therapies, such as antibiotic and antitoxin treatment. The idea of collaboration highlighted in one of Dr. Fankhauser’s main research projects extends to the interdisciplinary aspect of the Ada Project. For some, it may be hard to imagine how art and science can go hand in hand. To that, Dr. Fankhauser points out that “as we progress in our

Dr. Sarah Fankhauser, Oxford College Biology professor

academic or professional careers as scientists, philosophers, and humanists, [we’re] always going to have to work with people in different disciplines.” In her view, the creativity resulting from working with people from separate disciplines approaching the same problem from different perspectives far surpasses what any one person from any one field can accomplish. When asked about her experience working with first and second year students at Oxford College, whether on research or projects like the Ada Project, she replied that her experience has been “one of continual amazement.” “Every time I take a student to a conference, every time I submit a paper, people are astounded that it’s the product of first and second year students,” she said. She is constantly trying to do more with her students, guiding them while allowing a great degree of intellectual freedom.

Volume XV, Spring 2019 | 25

SPECIAL FEATURE

This spring, Dr. Sarah Fankhauser, a Biology professor at Oxford College, was at the forefront of an interdisciplinary project utilizing the arts to celebrate the women of STEM—extraordinary women who have contributed to various science and technology fields through the years. The event, dubbed the “Ada Project,” was a part of the Atlanta Science Festival and centered around a science play about the life of early computer programmer Ada Lovelace. “Every year, I try to do something with [the] Atlanta Science Festival to bring science to our campus and our community in an engaging way,” Dr. Fankhauser said. “I love being able to connect science with things that other people are already familiar with, like art.” In collaboration with theater students and Dr. Nick Fesette of the Theater Department, the play Ada and the Engine by Emory alumnus Lauren Gunderson, was ultimately chosen to be staged in March of 2019, alongside an art gallery showcasing the accomplishments of various women scientists. For Dr. Fankhauser, Ada and the Engine rang with a certain truth, in its portrayal of themes beyond math and science, such as the role of women in STEM fields and the meaning of motherhood for women working in STEM.

Teleheath & Aging Impact of Technology on Development in Later Life

Grace Xu

Pexel

Abstract

Telehealth â&#x20AC;&#x201C; the application of information and services with technologies designed to improve the quality of life of impaired individuals â&#x20AC;&#x201C;is becoming increasingly important in the provision of elderly care. Common telehealth application includes the implementation of communications technology and monitoring of health parameters. Although it is evident that these interventions are capable of increasing access to healthcare, the impact of these technologies on development in later life remains poorly understood. This review investigates the impact of telehealth on perceived perceptions of primary control, which remain strongly correlated with overall well-being. The findings indicate that telehealth interventions may effectively compensate for mental decline by facilitating adherence to medication schedules and self-care activities for chronic conditions. However, telehealth remains unable to address the inequities in health outcomes that may result from existing social disparities among diverse patient populations. Nonetheless, telehealth has demonstrated its efficacy in facilitating independent living by enabling increased access to providers so that patients may develop appropriate goals for their present levels of functioning.

MEDICINE

Introduction

The role of technology in improving access and quality of healthcare has become increasingly crucial, particularly for the senior population. The forefront of telehealth has enabled the rapid provision of medical support, and may therefore provide the greatest benefit for the 20% of persons who account for 80% of health expenditures (Dorsey and Topol 2016). Given that the elderly population is projected to double by 2050, the cost of caring for chronic illnesses will increase likewise (Bujnowska-Fedak and Grata-Borkowska 2015). Hence, telehealth has become uniquely positioned to address the specific needs of the elderly by enabling a means of direct contact with providers. Most importantly, the utilization of these technologies may directly facilitate independent living, which would therefore allow the elderly to retain greater primary control over their respective environments (Schulz et al. 2015). However, the adoption of telehealth by this population may be hampered by a lack of supporting studies, as well as a poor understanding of its impact on development in later life.

Background & Literature Review

Telehealth is broadly defined as the implementation of technologies capable of improving the quality of life for individuals with impaired functioning (Schulz et al. 2015). Given that elderly individuals remain at risk for developing multi-morbidities, means of continual access to specialized care are critical (Bujnowska-Fedak and Grata-Borkowska 2015). However, an increase in the prevalence of elderly individuals living alone, coupled with strong self-preference to maintain independent living, have underscored the importance of telehealth solutions to meet the unique needs of this patient population. Therefore, the development of technologies has become increasingly targeted towards the elderly and falls into two primary categories: a) monitoring of health parameters (e.g., wearable sensors and fall detectors) and b) communications technology (e.g., teleconsultations and virtual visits) (Bujnowska-Fedak and Grata-Borkowska 2015). Once the remote contact with providers has been established, the elderly effectively remain under constant

28 | Emory Undergraduate Research Journal

medical supervision within the comfort of their home environment. In other words, innovations in these areas have enabled older patients to receive a quality of care that would have otherwise been inaccessible outside of a traditional nursing home setting. Therefore, the advent of telehealth has enabled older patients to maintain greater primary control over the management of chronic conditions. Despite the potential benefits provided by the applications of telehealth, the field itself has failed to establish standardized methods of evaluation and consequently lacks a clear conceptual basis (Schulz et al. 2015). For example, recent developments in telehealth have led to a rapid increase of telehealth trials reporting positive outcomes. However, the conclusions of these small-scale studies should be viewed with caution, as more rigorous studies have found few, if any, improvements in health (Dorsey and Topol 2016). Therefore, the evidence supporting the quality of telehealth remains modest at best. As evidenced by the significant reduction in cost per visit, these technologies have evidently enabled an increase in access to care specialized for the care of the elderly (Schulz et al. 2015). However, there is limited research on how merely an improvement in access may translate into positive changes in the development of elderly individuals. For example, wearable sensors have repeatedly demonstrated their ability to detect and report falls, but have failed to interpret this data in a manner that would allow for meaningful outcomes (Schulz et al. 2015). Without the implementation of appropriate interventions (e.g., physical therapy, in-person visits) to complement remote medical surveillance, patients remain at risk for adverse health outcomes, effectively causing their perceptions of primary control to decline. As a result, there remains a need to expand our understanding of how exactly the environment and social context created by telehealth may shape the development of elderly individuals.

Findings

Table 1 presents the results of a two-phase prospective usability study for a robotic device designed to promote

Table 1. Dispensing and removal of medicine sachets, as documented by advanced in-home robotic devices to manage elderly patientsâ&#x20AC;&#x2122; medications.

Table 2. Clinical and healthcare use outcomes for elderly patients with depression receiving usual care plus psychoeducation or integrated telehealth.

MEDICINE

medication adherence for elderly home-care patients (Rantanen et al. 2017). Phase I (n = 17) was conducted in a single nursing home under controlled conditions. The device was then delivered to home-dwelling patients in Phase II (n = 27) to determine the efficacy of the device in an unsupervised environment. The overall trend was that the device was not only effective in facilitating adherence to medications, but was also correlated with overall levels of high patient satisfaction. Prior to implementation of the robotic device, 18% of home-dwelling patients reported missing doses at least twice per week (Rantanen et al. 2017). However, usage of the device enabled patients to retrieve the sachet on time for 98.7% of alerts (Rantanen et al. 2017). At the conclusion of the study, 89% of patients indicated that they would recommend the device for further use. Table 2 presents the results of a 3-month intervention for the homebound elderly individuals who were diagnosed with chronic illness and depression. Participants assigned to the control condition, designated as Usual Care Plus Psychoeducation (UC+P), simply received in-home

nurse services and weekly counseling sessions (Gellis, Kenaley and Ten Have 2014). Patients assigned to the experimental condition, designated Integrated Telehealth Education and Activation of Mood (I-TEAM), communicated with nurses via an in-home monitor connected to the primary healthcare station (Gellis, Kenaley and Ten Have 2014). Overall, I-TEAM participants reported significant improvements in baseline measures of mental health. For example, patients assigned to the telehealth cohort reported mean scores that remained 50% less than those of the usual care cohort on assessments of depression. Telehealth participants were also able to significantly outperform those assigned to usual care in an assessment of problem-solving and coping skills (Gellis, Kenaley and Ten Have 2014). Figure 1 presents the adjusted means for the number of days spent on diabetes self-care activities for elderly patients. Under the Informatics for Diabetes Education and Telemedicine project (IDEATel), participants received either usual care or a telehealth intervention. Over the span of five years, white, black, and Hispanic patients would engage

Volume XV, Spring 2019 | 29

MEDICINE

Figure 1. Adherence to diabetes self care for white, black and Hispanic telemedicine participants of the IDEATel project. in monthly tele-visits with nurse case managers and dieticians through a Home Telemedicine Unit (HTU). During these sessions, the educator and diabetic patients would develop behavioral goals designed to improve adherence to self-care. In general, telehealth participants maintained a significant difference in the number of days spent on selfcare when compared with those who received usual care. Both groups indicated an initial increase in adherence at the one year period, but the adjusted means for telemedicine patients continued to remain significantly greater than those in usual care for the duration of the study. This gap in patient outcomes is most clearly demonstrated at conclusion of the study, in which the experimental cohort reported an adjusted mean of 32.48 days spent on self-care while the control cohort reported only 30.33 days. Figure 2 presents the number of days spent on selfcare among telehealth participants stratified by race. Overall, the existing racial differences in health outcomes increased over the course of the intervention (Trief et al. 2013). At baseline, white participants reported an average of approximately 30 days spent on self-care, while black and Hispanic participants reported 28 and 27 days respectively. Over the course of the intervention, each racial cohort reported an improvement in the number of days with implementation of self-care. However, minority participants remained less adherent to diabetes self-care across all annual data points. The disparity between white and minority participants was most exacerbated at year three, at which the former reported an increase to approximately 34 days, while the latter remained under 30 days.

Findings

Telehealth interventions can aid the aging population by compensating for the loss of primary control. As evidenced by the implementation of the robotic device, telehealth has enabled patients to become independent in main-

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Figure 2. Adjusted means from model predicting overall diabetes self-care outcomes by intervention vs usual care group. taining adherence to medications. Likewise, the I-TEAM study has demonstrated that the ease of access to providers during moments of low perceived primary control, such as depressive episodes, was an important factor in facilitating the development of problem-solving skills for telehealth participants. Lastly, as indicated by the increase in number of days spent on self-care, the IDEATel study has shown that televideo visits from educators were highly effective in supporting a diverse cohort of participants to develop appropriate, health-oriented goals for their present levels of functioning. Therefore, telehealth may help elderly individuals engage in proactive behaviors to strengthen their perceptions of self-sufficiency. As a result, these devices may help to offset the mental and physical limitations that accompany the process of aging. However, the IDEATel study has demonstrated that telehealth may merely be transferring the systemic inequalities of in-person care to a new environment. Although the study attempted to compensate for racial differences by providing educators from the same cultural backgrounds, black and Hispanic participants remained less adherent to diabetes-related self-care. Even though the design of the telehealth intervention was intended to reduce racial disparities, the baseline demographic characteristics played a larger role in shaping the outcome of the study. As indicated by these results, technology is evidently capable of facilitating development in later life, but it lacks the capability to challenge the social disparities inherent to the delivery of traditional care. Thus, the present social constraints of traditional care may have merely become transferred to a new environment. However, an increase in access to technologies may help to reduce racial inequities in health outcomes. Due to the social barriers of the patient-provider relationship, black and Latino patients who have access to a mobile cell phone have become more likely than white patients to rely on the Internet for health information in times of strong need (Ray

et al. 2017). These technologies have allowed minorities to obtain greater access to health information, which may enable these underserved populations to increase their utilization of healthcare. Given the potential of these findings to reduce the racial divide in health outcomes, future research on the relationship between social factors and telehealth is needed. As the makeup of the US population begins to shift, these demographic trends underscore the need to parse out the present disagreements on the efficacy of technologies, particularly for the elderly and minority populations.

References

Bujnowska-Fedak, Magdalena, and Urszula Grata-Borkoska. 2015. “Use of telemedicine-based care for the aging and elderly: promises and pitfalls.” Smart Homecare Technology and TeleHealth. Dorsey, E. R., and E. J. Topol. 2016. “State of Telehealth.” N Engl J Med 375(2):154-61. Gellis, Z. D., B. L. Kenaley, and T. Ten Have. 2014. “Integrated telehealth care for chronic illness and depression in geriatric home care patients: the Integrated Telehealth Education and Activation of Mood (I-TEAM) study.” J Am Geriatr Soc 62(5):889-95. Rantanen, P., T. Parkkari, S. Leikola, M. Airaksinen, and A. Lyles. 2017. “An In-home Advanced Robotic System to Manage Elderly Home-care Patients’ Medications: A Pilot Safety and Usability Study.” Clin Ther 39(5):1054-61. Ray, R., A. A. Sewell, K. L. Gilbert, and J. D. Roberts. 2017. “Missed Opportunity? Leveraging Mobile Technology to Reduce Racial Health Disparities.” J Health Polit Policy Law 42(5):901-24. Schulz, R., H. W. Wahl, J. T. Matthews, A. De Vito Dabbs, S. R. Beach, and S. J. Czaja. 2015. “Advancing the Aging and Technology Agenda in Gerontology.” Gerontologist 55(5):724-34. Trief, P. M., R. Izquierdo, J. P. Eimicke, J. A. Teresi, R. Goland, W. Palmas, S. Shea, and R. S. Weinstock. 2013. “Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project.” Ethn Health 18(1):8396.

MEDICINE Grace Xu is a junior majoring in Biology. She currently serves as a Peer Mentor for the Research Partners Program and conducts clinical research in the Division of Renal Medicine. She is passionate about the intersection of health and humanities, especially with regard to the future of telehealth. In her free time, she enjoys long-distance running and writing nature poetry.

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Evaluation of Ecosystem Services

Ishan Saran, Esteban Ramos,

Emily Rexer, Sankee Mummareddy, Shivam Saran, Rishabh Saran, Diego Gonzalez Hernandez

Pexel

Abstract

Ecosystem services are the services that the environment provides for both human consumption and utilization. Often, evaluating the economic impact of destroying such ecosystem services can be difficult and is thus ignored when building land projects. This results in millions of dollars potentially wasted and has significant ramifications economically, environmentally, and ethically. We create an ecosystem service valuation model to understand the true cost of land use projects by modeling the value of the unaffected ecosystem services and the extent in which they are impacted by the land use development. We use a summation model as a function of the project itself and the area which the project is displacing. We test our model on six different case studies, finding the total monetary cost of the ecosystem services affected by land use projects as such: Project

Ecological Cost (USD)

Road construction in Cairo, Egypt Housing in Washington, US Facebook MPK20 in CA, US Road construction in Hobart, Australia Vía Verde Pipeline in Puerto Rico Nicaragua Canal Project

$219 $502 $19,110 $1.7 million $642 million $3.16 billion

We also project our model into the future and find that the system is chaotic. It quickly diminishes in accuracy into the future but is fairly robust to the parameters as defined by our model.

Introduction

MATHEMATICS

We attempt to create a valuation model of ecological services to quantify the economic costs of environmental degradation caused by land use development. We model land use development projects of varying sizes and in different locations. In order to evaluate the effectiveness and implications of our model, we perform a sensitivity analysis and project our model into the future.

Pexel

Definitions An ecological (or ecosystem) service is any service provided by an ecosystem which could be beneficiary to humans. Ecological services can be categorized into use (those which can be directly or indirectly used by humans) and non-use (those which cannot be used by humans) and controversy often arises with non-use ecological services as it is contentious to place a price on that which offers no value. We choose to consider non-use ecological services as ”subservices”27. The ecological services we consider in-

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clude but are not limited to: carbon sequestration, water filtration, flood prevention, erosion prevention, recreation, biodiversity protection, fire prevention, timber, fuel wood and charcoal, eco-tourism, micro-climate regulation, biochemicals, natural irrigation, plants and vegetable food, hydro-electricity, deposition of nutrients, gas regulation, soil formation, cultural use, drainage, and science/research. The valuation of a given service is the monetary value assigned to that service. Since the value of a service must be greater than or of equal value to the price for consumers to purchase a service, any monetary estimation of an ecological service will underestimate the true value of the service. Direct use services describe measurable services produced by the ecosystem which directly benefit humans, such as carbon sequestration and ground water recharge. Indirect use services are services that don’t directly benefit humans, but augment the benefits of other direct use services; e.g. biodiversity. Since this is difficult to measure, this often results in calculating their demand side valuation; i.e. the value the ecosystem service provides for humans. We use The Economics of Ecosystems and Biodiversity (TEEB) Database27 as sources for these values, a compiled database of ecosystem services values from many ecosystem valuation studies. The values used for the ecosystem services were calculated based on three well-established methods for ecosystem valuation: benefit transfer, direct market pricing, and replacement cost techniques. The biome is the naturally occurring flora and fauna occupying a habitat and can be broadly categorized into terrestrial and marine17, although we only consider terrestrial. The biome types we consider are: tropical forests,

inland wetlands, coastal wetlands, cultivated, coral reefs, fresh water, coastal, multiple ecosystems, woodlands, deserts, forests [temperate and boreal], grasslands, urban, and marine.

Assumptions

Clean water is accessible and uncontaminated water sources vary little between each other. Since water can be piped or trucked in, we assume that it is accessible and in our model we consider the distance to clean water. Areas in the same ecosystem classification are equally productive. Even in ecosystems that are the same classification there can be huge variety. We assume that each biome is relatively uniform throughout so that grouping by biome is sufficient to differentiate between projects. Any impact scales linearly. An increase in the area linearly affects the factors used to calculate the monetary representation of the ecological cost. For example, if one tree sequesters N kg of CO2, then two trees sequester 2N kg of CO2. Energy costs accurately reflect the value of ecological services, and accurately translate the cost of those services in different regions with differing energy costs. We translated some ecological costs into monetary value by calculating the approximated energy of ecological services and using the energy cost in the region. We are assuming that it is possible to estimate a conversion factor. There is a non-linear inversely proportional relationship between the distance from an urban areas and the value of ecosystem service25 28. Therefore, we assume a relationship between urbanization and ecosystem services. This means that access to clean water, biodiversity, and other similar services are affected by urban proximity.

corresponds to a location which is very close in proximity to an urban setting, defined as 5 km or less. A value of one corresponds to a rural location far from an urban environment, at least 50 km. This is because urban areas have irrigation services and other utilities already in place. In rural settings the landscape needs to be torn apart more to get the resources necessary, which leads to more damage to the ecosystem services that the land provides. We use a logarithmic scale because previous literature indicates that this relationship is non-linear28. For the eco-friendly index, a value of zero corresponds to a company which puts no effort into reducing its carbon footprint or using other environmentally friendly practices. A value of one corresponds to a hypothetical company which is able to symbiotically live in the ecosystem without damaging any of the services and fully operating within the parameters of the ecosystem. For example, the Apple Park built in California, US would have a relatively high eco-friendly index since it is the worldâ&#x20AC;&#x2122;s largest naturally ventilated building with 7,000 trees planted around campus, and 100% renewable energy powering the campus19. For the six case studies we estimate an index value. In reality, before a construction project is started, the company can use an index for determining this, such as the 2017 State of Green Business Index8.

MATHEMATICS

Model

Model Variables We used different methods to evaluate the monetary cost of different ecological services depending on the service. We use the equations described below for carbon sequestration and water filtration and purification. Where we cannot estimate the direct cost of a service we use costs from the TEEB Database27. TC = (D + â&#x2C6;&#x2018;i Si)(1 + Purban)(1 â&#x2C6;&#x2019; E)

(1)

In order to avoid double-counting, we discard any values from the TEEB data set which deal with carbon sequestration, water purification, water filtration, and any ambiguities related to water or carbon dioxide purification. The urban proximity index and the eco-friendly index both range from zero to one and are weighting factors which affect the final price. For the urban proximity index, a value of zero

Figure 1: The most relevant ecosystem service categories by number of occurrences, not broken into sub services. Any service which accounted for less than 3% of the resources was omitted from the graph but not from analysis.

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We use a summation model with a time-step of one year for the use of ecological features22.

D(C, W) = C + W

(2)

Here we add together the monetary cost of the energy used by carbon sequestration and the monetary cost of the energy used to filter water. This is the total cost of the Direct Use services. EC = ECO2 ET p

(3)

This equation finds the energy of carbon sequestration per square meter of canopy cover. This is calculated by multiplying the energy of carbon sequestration per pound of CO2 by the conversion factor to turn this value into energy of carbon sequestration per meter squared. Then this is multiplied by the energy efficiency of photosynthesis.

C = E$EC F% A

(4)

This equation calculates the cost of the energy used by carbon sequestration. The energy of carbon is calculated by taking the total area and multiplying it by canopy cover percent in order to estimate the total area in which photosynthesis is occurring. We then multiply the total canopy cover by the energy produced per square meter of canopy cover to find the total energy of carbon sequestration in the area, and convert that into US dollars by using the cost of energy relative to the location of the land use project.

W = Pw A(Ď H2O)EmE$

(5)

MATHEMATICS

This equation calculates the cost of the energy used by the soil to filter water. By multiplying precipitation per square meter and area of the land use project we find the total precipitation in the area. We then multiply by the solar transformity to end up with the total amount of emergy required to clean the water from precipitation. We can convert this into US dollars by using the cost of energy relative to the location of the land use project. Purban = log(x/5)

(6)

This equation calculated the index for urban proximity and it works for values between 5 and 50 kilometers. If the environment is close enough, or less than 5 kilometers, then it is considered to have an index of 0 and if it is farther than 50 kilometers it is considered rural and to have an index of 1. The logarithmic scale, again, is because of the non-linearity between urban diversity and ecosystem services25. Table 1: Symbols, definitions and constants

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Case Studies

By testing case studies, real world examples that can be applied to our model, we can confirm that our model’s results are logical and on the right scale. The following case studies are listed in order from smallest to largest area (m2). Housing in Washington, United States14 3 24 23 The impact of individual housing on ecosystem services is generally hard to measure. In most case housing is built as parts of large projects that disrupts large areas of an ecosystem, yet in this case study we model a theoretical housing project in rural Washington state. Project Cost without environmental services considered: Environmental services cost per year: Combined cost after the first year: Percentage increase:

$300,000 $502 $300,502 0.14%

This projects large distance from the urban environment and its location in a high canopy coverage biome were factors expected to be very influential in the price inflation for this project yet its small size and is eco-friendly index resulted in a very low environmental systems cost compared to its total monetary cost. In this case the damaged ecosystem services would not be significant in project consideration. Facebook Building 20 in Menlo Park, United States13 9 4 5 Large companies are constantly building or remodeling their headquarters to accommodate to their significant growth. Facebook’s MPK Building 20 expansion serves as a good example for projects such as these.

The vast majority of large company headquarters are found in urbanized areas in which local ecosystem services have already been damaged so even when considering the large scale of such a project its environmental damage is relatively limited. The ecosystem services cost would likely not influence the development of the project. Road construction in Hobart, Australia6 12 18 1 Hobart is the regional capital of Tasmania, Australia. Unlike the vast majority of Australia, Tansmania’s biome is classified as a rain forest with unique flora and fauna at risk by urban development. Average road project costs in Australia are high and the value of the ecosystem services in such a diverse part of Australia is likely to increase the project cost significantly.

The cost of ecosystem services would be significant in this land use project as the roads would affect a diverse and bountiful ecosystem. As this project is being built relatively far away from the urban centers it would impact pristine natural environments with a high value for ecosystem services. Road construction in Cairo, Egypt20 7 Cairo is the capital of Egypt and considered an economic and cultural center for the entire region, yet it is also known for its abysmal traffic. Road project costs in Egypt are relatively cheaper than other parts of the world and the desert environment of Egypt suggests a project of this type should be generally cheaper both in construction cost and in possible damage to ecosystem services. Project Cost without environmental services considered: $21 million Environmental services cost per year: $218 Combined cost after the first year: $21 million Percentage increase: 0.000%

Considering this project is being built in a desert the damages to ecosystem services would be low. The desert environment of Egypt does not provide many ecosystem services and in truth it does not need to. Considering local characteristics, the most significant part of the model that would be affected by the construction would be the direct use of water recharge, yet due to Egypt’s significantly low precipitation this ecosystem service does not get much use to begin with. The proposed Vía Verde Pipeline project in Puerto Rico21 2 26 The Vía Verde Pipeline Project was proposed as a landmark energy project to satisfy Puerto Rico’s energy needs in 2009. The project was never completed once it proved to be controversial due to its planned route which would have covered around seven square km of Puerto Rico’s untouched rain forest. Since this would potentially place many local communities and endangered species at risk the monetary ecological cost would be significant. Project Cost without environmental services considered: $800 million Environmental services cost per year: $642 million Combined cost after the first year: $1.442 billion Percentage increase: 44.5%

The Vía Verde Pipeline would significantly damage the vast ecosystem services that the ecosystem provides to the point the project is likely not worth its cost.

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MATHEMATICS

Project Cost without environmental services considered: $269 million Environmental services cost per year: $19,110 Combined cost after the first year: $269 million Percentage increase: 0.007%

Project Cost without environmental services considered: $73 million Environmental services cost per year: $1.7 million Combined cost after the first year: $74 million Percentage increase: 2.3%

The proposed 2013 Nicaragua Canal project between the Pacific and Atlantic Oceans16 11 Recently the Nicaraguan government proposed a massive project to construct a new canal to connect the Pacific and Atlantic oceans. This proved unpopular since the canal would cut through heavily wooded areas of Nicaraguan rain forest and cause massive disruption to the ecosystem. Project Cost without environmental services considered: $45 billion Environmental services cost per year: $3.16 billion Combined cost after the first year: $47.16 billion Percentage increase: 6.6%

The Nicaragua Canal project was always expected to significantly affect the environment around where it was built due to the scale of the project. While it would likely not significantly affect its construction it still demonstrates a significant impact.

Discussion

MATHEMATICS

A significant goal from the onset of this project was the creation of a land ecosystem evaluation model that could be applied at a global scale to a series multiple different projects with different rates of impact. To achieve this goal, we developed carbon sequestration and water discharge models that took inputs that were valid in every environment and location. We incorporate the TEEB database as it provided a standardized data set for the different biomes our model encapsulates. By using case studies that varied in magnitude and cost, we were able to determine that our model correctly predicted the monetary cost of ecological services. Future Projections We project our model into the future by performing simple random perturbations. We perform a kernel density estimation at the graphs corresponding to how certain we are that our model is accurate at a time t after our initial construction. We see that as time goes on, the certainty of our model quickly dissipates, implying some sort of chaotic system at work. The fundamental problem of evaluating ecosystem services are that they are highly sensitive to initial conditions, but more so to time. The value placed on a given service is always in reference to the zeitgeist of the population at large. Unfortunately, this poses its own problems as a developing nation might disregard the cost of ecosystem services while nation building but may later realize its necessity once the cost has already scaled up. However, the rate at which this cost rises is a function of a whole network of individual actors. Thus, while our model might be robust to initial conditions excluding time, as soon as we factor in time, we immediately must reevaluate our model.

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Figure 2: The change in ecosystem services valuation over time. Sensitivity Analysis We perform a sensitivity analysis by varying initial parameters of the values in our model. We vary the eco-friendly and urban proximity index from -0.1 to 0.1. We also vary other initial parameters of ecosystem services that are given by the TEEB database as well as carbon sequestration parameters and water filtration parameters with bounded random values. Our model, for all six of the case studies, vary only within one order of magnitude for the value at present, which suggests some stability. Strengths and Weaknesses Strengths: • Our constants are backed up by validation tests, which confirm our model. • Multiple inputs provide an accurate assessment of the ecological value of a chosen location. • The model integrates multile kinds of valuation, bridging the gap between supply value models and demand value models. Weaknesses: • We do not include all possible ecological factors that could contribute to the monetary value of the ecosystem. • We assume that grouping biomes together is enough to differentiate between products. • Our model does not scale well into the future. It appears the system is chaotic and sensitive to initial conditions and therefore is not representative of the value of ecosystem services as a function of time.

References: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

12. 13. 14. 15. 16.

17. S. Charles Kendeigh. Animal ecology, 1961. URL https://www. biodiversitylibrary.org/bibliography/7351#/summary. 18. Kristyn Maslog-Levis. First urban tree canopy cover benchmark in australia. URL https://citygreen.com/blog/first-urban-tree- canopy-cover-benchmark-in-australia/. 19. Andrea Miller. Apple’s headquarters, facilities now powered by 100 percent renewable energy, 2018. URL https://abcnews. go.com/ Technology/apples-headquarters-facilities-now-pow ered-100-percent-renewable/story?id=54362901. 20. Hanan Mohamed. Electricity minister reveals new 2018/2019 electricity prices, 2018. URL http://www.egypttoday.com/Arti cle/3/51993/Electricity-Minister-reveals-new-2018-2019-elec tricity-prices. 21. U.S. Army Corps of Engineers. Va verde natural gas pipeline project. URL https://www.vermontlaw.edu/sites/default/files/ Assets/enrlc/cases/protecting-puerto-ricos-rich-biodiversi ty- from-proposed-via-verde-natural-gas-pipe line/2012-01-30%20--%20UPR-Via%20Verde%20Public%20 Comments%20on%20Draft%20EA.pdf. 22. Marco Casazza Elliot T. Campbell Biagio F. Giannetti Mark T. Brown Qing Yang, Gengyuan Liu. Development of a new framework for non- monetary accounting on ecosystem ser vices valuation. 34, 2018. 23. Mike Rosenberg. Home prices rising faster in washington than in any other state, 2016. URL https://www.seattletimes.com/ business/home-prices-rising-faster-in-washington- than-in-any-other-state/. 24. Tom Trimbath. Seattle houses are getting bigger while households get smaller, 2016. URL https://seattle.curbed. com/2016/7/6/12094572/seattle-houses-bigger-households. 25. Christopher Trisos. Urbanization effects on biodiversity, 2015. URL https://www.sesync.org/project/postdoctoral-socio-environ mental-immersion-program-2015/urbanization-ef fects-on-biodiversity. 26. USDA. Forests of puerto rico, 2014. URL https://www.srs.fs.usda. gov/pubs/ru/ru srs121.pdf. 27. S. Van der Ploeg and R.S. de Groot. The teeb valuation database a searchable database of 1310 estimates of monetary values of ecosystem services., 2010. 28. Maibritt Pedersen Zari. The importance of urban biodiversity an ecosystem services approach, 2018. URL https://medcraveon line.com/BIJ/BIJ-02-00087.

My name is Ishan Saran and I am a second-year student from Las Vegas, NV. Currently, I am studying physics at Emory and I am on track to become a doctor. My research interests are in computational modeling, machine learning, and AR/VR programming. The future envisioned by the science fiction writers of the 60s is quickly approaching us (if not already here) and I’m excited for the developments in technology and hope to catch the wave riding forward. I am also an avid chess player, break dancer, and debater… although I’m not too good at any of those.

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MATHEMATICS

Australian biomes. URL https://mainweb-v.musc.edu/cando/aus dwnun/biom.html National land cover database, percent tree canopy cover age-puerto rico. URL https://databasin.org/datasets/ ae0acddccbc548df9396d48078ddfd64. Electricity rates by state (jan. 8, 2019). URL https://www.chooseen ergy.com/electricity-rates-by-state/. Facebook campus expansion. URL https://www.menlopark. org/995/Facebook-Campus-Expansion. Menlo park electricity rates. URL https://www.electricitylocal.com/ states/california/menlo-park/. Australian tropical savanna climate, 2001. URL http://www.blue planetbiomes.org/savannaaustraliaclimpage.htm. Egypt forest cover, 2005. URL https://rainforests.mongabay.com/ deforestation/archive/Egypt.html Sustainable development goals, 2015. URL https://sustainabledevel opment.un.org/sdgs. Facebook spends $269 million on headquarters, May 2016. URL https://greenbuildingelements.com/2016/05/12/face book- spends-269-million-headquarters/. Erv Evans. Tree facts. Website. URL https://projects.ncsu.edu/proje ct/treesofstrength/treefact.htm. Nathaniel Parish Flannery. Nicaraguan canal mega-project faces de lays and opposition, Jan 2014. URL https://www.forbes.com/ sites/nathanielparishflannery/2014/01/07/nicaraguan-canal- mega-project-faces-delays-and-opposition/#5a909f115041. Australian Government. Road construction cost and infrastructure procurement benchmarking: 2017 update, 2017. URL https:// bitre.gov.au/publications/2018/files/rr148.pdf. Kelsey GraeberHaving. Construction tops $1b at facebooks west campus, May 2018. URL https://www.buildzoom.com/blog/ facebook- west-campus-1b. Davey Resource Group. Urban tree canopy assessment, 2011. URL http://file.dnr.wa.gov/publications/rpurbanbonneyLake ca.pdf. James Alan Bassham Hans Lambers. Photosynthesis, 2018. URL https://www.britannica.com/science/photosynthe sis/Energy-efficiency-of-photosynthesis. Anna Hochleitner. La construccin del canal interocenico en nica ragua: situacin de partida y efectos en el desarrollo nacional, 2015. URL https://library.fes.de/pdf-files/bueros/ fesamcen tral/12056.pdf.

My name is Esteban Ramos and I developed an interest in Math/CS late in my education, only realizing my interest after taking a few classes my sophomore year. I was not exposed to the most interesting aspects back home in Honduras and as a result never realized they were something I could dedicate my life to. Thanks to the influence of great professors and educational opportunities I developed the passion to pursue a research career in those fields. Research is at the heart of academia and it is the enterprise that I hope to dedicate myself to in the coming years.

MATHEMATICS

Emily Rexer is a third year undergrad at Emory University majoring in Mathematics and Computer Science. She is working with the Saikawa Labs to build an air pollution monitoring system around Emory, and is interested in furthering her education and applying her knowledge to real-world problems.

My name is Sankee Mummareddy, and I am a rising junior majoring in mathematics and economics. Currently, I am on the pre-med track, and I one day hope to pursue a MD-PhD program. Outside of academics, my major interests include dancing (breakdancing, modern, and hip hop), reading (favorite books: Freakonomics and Thinking, Fast and Slow), and playing tennis (favorite player: Roger Federer). Additionally, I love volunteering at hospitals and animal shelters. As matter of fact, I am a dog trainer for blind service dogs!

40 | Emory Undergraduate Research Journal

Shivam is planning on studying computer science and is fascinated by political science. Currently President of Speech & Debate, his interests cover a wide domain, from gun violence to neural networks, and he is always pursuing a challenge. He is a nationally ranked biomedical and public forum debater, has won numerous awards in public speaking and scientific endeavors, is a Conrad Spirit of Innovative Challenge finalist.

Rishabh is planning on majoring in computer science. His interests are in machine learning, web design, and communications. He is also a DECA State Champion, a nationally ranked biomedical debater and a Conrad Spirit of Innovation Challenge finalist.

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MATHEMATICS

My name is Diego Gonzalez Hernandez and I was born and raised in Guatemala City, Guatemala. From an early age, I became interested in Astronomy thanks to some TV shows that talked about many astronomical phenomena. After some months of showing interest in the topic, my parents gave me a telescope which I have kept with me for several years to look up to the stars! In high school, I cemented my interest in science by competing in the Guatemalan Science Olympiads. Now, I am a 2nd year studying physics at Emory.

From Lhasa to Beijing

The Significance of the Fifth Dalai Lama's Visit to the Qing Court in 1652-1653 Tenzin Dudul Taklha

Image by nrxfly from Pixabay

Introduction

HISTORY

poral and spiritual authority over all of Tibet. From 1652 to Evelyn Rawski’s 1996 presidential address to the As- 1653, he visited the Qing court at the invitation of the Shunsociation of Asian Studies, Reenvisioning the Qing: The Sig- zhi Emperor. At this time, both the Qing Dynasty and the nificance of the Qing Period in Chinese History, challenges Dalai Lama institution were quite new to formal power, havthe long-held belief that the key to Qing success was that ing gained rulership in 1644 and 1642, respectively. The Fifth the Manchu had been “Sinicized” by the very people they Dalai Lama, a renowned writer, details the entire journey in conquered. Instead, Rawski argues the opposite: “the key his autobiography. On the Qing side, it is unsurprising that to Qing success, at least in terms of empire building, lay in several Chinese-language sources recorded this visit as well, its ability to use its cultural links with the non-Han peoples the most prominent one being the Qingshilu, or the “Veriof Inner Asia and to differentiate the administration of the table Records of the Qing Dynasty”. In this paper, I will explore the visit addressing non-Han regions from the motivations from both administration of the former the Qing court’s and the 1 “The brilliance in the Manchu’s successful Ming provinces.” This is not Dalai Lama’s perspecquest to build a vast and diverse empire lay to deny the fact that Manchu tives. The two sources foleaders portrayed themselves in their ability to adopt the various customs cus on different aspects. as Chinese rulers; they did, of their subject.” Tthe main concern from as evidenced by their acquisithe Chinese viewpoint tion of the Chinese language, is with implementation acceptance of Confucianof protocol. This is most apparent in the Qing court’s dis2 ism, and their interest in Chinese art and literature. The brilliance in the Manchu’s successful quest to build a vast cussion on whether or not the Emperor ought to meet the and diverse empire lay in their ability to adopt the various Dalai Lama outside of Beijing. On the other hand, the Dalai customs of their subject. With the Chinese, they adopted Lama’s autobiography is heavily influenced by his religious Chinese customs, with the Tibetans, they incorporated Ti- practice. Zahirudduin Ahmad notes, “this monkish learning betan customs, and with the Mongols, they incorporated is seen not only in the language used—it abounds in scripMongol customs. Rawski’s main concern regarding the Si- tural quotations and allusions—but also in the view of the nicization theory is that it is heavily reliant on the official whole word... secular affairs play a very minor part in that 5 Chinese-language records. The Qing court conducted its of- world.” Drawing from both sides, I will break down this visficial business in both Chinese and Manchu. Until recently, it while challenging the sinicization of the Manchu’s theory historians ignored the documents written in Manchu, argu- and demonstrate, as Rawski argues, that the Qing “drew on ing that they would be no different from the Chinese-lan- multiple sources and adapted ideologies of rulership and ad6 guage sources.3 In the 1980s, access to Manchu-language ministrative structures.” resources improved, and subsequently, more historians began to study the Manchu language. Rawski determines that “Manchu-language documents were a vital part of an early Qing communications network that frequently bypassed Han Chinese officials.”4 This was a major breakthrough; it allowed historians to understand the perspective of the Manchu ruling class. This revelation gave birth to the school of New Qing History, stimulating an entirely new debate in the field. One can conclude that the Chinese-language sources have their limitations when it comes to studying the Qing Dynasty. When two distinct cultures meet, such as the Han and the Manchu, it is necessary to understand the perceptions and characteristics of each. This holistic approach allows us to paint a fuller picture and draw more accurate conclusions. Rawski’s presidential address and its lessons provide the methodological framework for this paper. The Fifth Dalai Lama, often referred to as the “The Great Fifth”, was the first Dalai Lama to exercise both tem-

Relationships between the Manchu, Mongolian, and Tibetan It is impossible to comprehend the details of this visit without understanding certain political and religious intricacies in China and Tibet in the seventeenth century. It is especially important to understand the dynamics between the three groups: the Manchu, the Mongolians, and the Tibetans. I will begin by introducing the setting of this historic visit. The Qing dynasty, established in 1636 by Hong Taiji, succeeded the Ming dynasty (r. 1368-1644). Formerly known as the Jurchen, the Manchu people’s ancestors reigned in Northern China between A.D. 1122 and 1234. They were known as the Jin dynasty. Nurhaci, Hong Taiji’s father, launched the Manchu conquest of China when he declared himself “Khan”, the ruler of the second Jin dynasty. Traditionally, rulers in China have used the concept

1 Evelyn Rawski, “Presidential Address: Reenvisioning the Qing: The Significance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 831. 2 Evelyn Rawski, “Presidential Address: Reenvisioning the Qing: The Significance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 834. 3 Evelyn Rawski, “Presidential Address: Reenvisioning the Qing: The Significance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 829. 4 Evelyn Rawski, “Presidential Address: Reenvisioning the Qing: The Significance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 829. 5 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 38. 6 Evelyn Rawski, “Presidential Address: Reenvisioning the Qing: The Significance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 842.

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of the Mandate of Heaven to gain legitimacy. This notion claims that heaven bestows its mandate to the rightful ruler, the son of heaven. Nurhaci posed as a reformist, the new heaven-approved ruler and notably, “to those Chinese with education who surrendered, he offered a chance of serving in the growing Jurchen bureaucracy, and senior Chinese officials who came over to his side were offered to marriage into his family, honorific titles, and high office.”7 After Nurhaci’s death in 1626, Hong Taiji took command of the conquest army. Nurhaci’s willingness to adopt Chinese methods of rule was apparent, but Hong Taiji took it to another level. He imitated the Ming court’s system by establishing six ministries, followed the traditional Confucian method of administering examinations to select candidates for civil service, and employed Chinese officials throughout his new bureaucracy to the point that some of his Manchu advisors felt he was being too generous.8 Most significantly, Hong Taiji declared the formation of the Qing dynasty, a direct threat to the perishing Ming. Unfortunately, he died before the Manchu were able to complete their conquest of China. In 1644, his son, Shunzhi, was enthroned in the Forbidden City. Once in power, the Qing made several changes such as requiring men to abide by the Qing hairstyle, forbidding

"Traditionally, rulers in China have used the concept of the Mandate of Heaven to gain legitimacy... that heaven bestows its mandate to the rightful ruler, the son of heaven."

7 Jonathan Spence, The Search for Modern China. (New York: W.W. Norton & Company, 2013), 28. 8 Jonathan Spence, The Search for Modern China. (New York: W.W. Norton & Company, 2013), 28. 9 Jonathan Spence, The Search for Modern China. (New York: W.W. Norton & Company, 2013), 38. 10 Jonathan Spence, The Search for Modern China. (New York: W.W. Norton & Company, 2013), 39. 11 Thomas Laird, The Story of Tibet. (New York: Groove Press, 2006), 164. 12 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 12. 13 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 117.

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HISTORY

the practice of foot binding, and lessening the influence of court eunuchs.9 However, the system of government under the Ming remained largely intact. The major difference was that each ministry was led by two presidents, one a Manchu and one a Chinese. This type of bi-ethnic leadership was established at lower levels as well.10 This serves as an early example of how the Qing adapted ideologies and administrative structures. They were quick to realize that they were a small minority and the system in place could be modified through minor adjustments. This is not to say that the Manchus became Chinese. Thomas Laird demonstrates this as he points out that intermarriage between the Manchu and Chinese was forbidden, Manchu officials had to speak and read Manchu, and they were assigned to oversee every Chinese bureaucrat in order to ensure dominance.11 However, by adopting various Ming policies, at least in the eyes of the Chinese officials, the Qing had inherited the traditional Ming view of the world.

This traditional view, often interpreted as the “Sino-centric world order” or the “tribute system”, emphasized the notion that China stood as the center of civilization and its culture was unmatched by others. It is understandable how or why this outlook came about. For thousands of years, Chinese dynasties dominated their surroundings without threat from other great centers of civilization. To conduct trade between China and the surrounding countries, a tribute system was established as an institution to not only trade international goods, but to maintain diplomatic relations as well. Foreign rulers would present gifts to the Chinese emperor in exchange for not only return gifts, but also for the recognition of the ruler’s leadership as confirmed by the Chinese emperor. There have been disagreements about the beginnings of the tribute system among scholars; John Fairbank claims that it originated during the Zhou dynasty, Morris Rossabi contends the Han dynasty, and John Willis favors the Ming dynasty.12 Nonetheless, it is safe to say this system was already in place when the Qing took over China. In accordance with the Mandate of Heaven, the Chinese Emperor not only served as the ruler of China, but as the chosen ruler of all under heaven. This gave birth to a unique form of foreign relations, and in particular, a peculiar method of guest ritual at the Chinese court. Hevia highlights three general rules: In the first place, the guest is not invited to the Qing court. Rather, the lesser lord requests permission to enter the imperial domain. Second, because the entire process appears to be about forming superior/inferior relations, equality is irrelevant. Third, these features of Guest ritual appear, in turn, to be infused with an explicit morality, rather than influenced by etiquette or manners that may, but by no means must, buttressed by moral principles.13 The Fifth Dalai Lama’s visit to Beijing did not fit within the protocols of this rigid guest ritual. The Qing Court overlooked the formalities of the traditional tribute system, indicating that the Qing did not conform to the Sino-centric view of the world. Rather, they successfully incorporated this Chinese ideology into their system of rulership and in turn, developed a pragmatic approach which did not completely disregard the traditional Sino-centric view. I will discuss this in detail after I describe the political landscape in Tibet and Mongolia. The relationship between the Mongols and the Tibetans extends back to the Yuan Dynasty in the thirteenth century. Like the Qing, the Yuan were a conquest dynasty that absorbed the Chinese state into the much larger political unit. The founder of the Yuan, Khublai Khan, received

HISTORY

instructions in Tibetan Buddhism from Phagpa Gyaltsen, a young Tibetan monk who was a guest at the Mongol court. In return, Khublai Khan appointed Phagba as his imperial preceptor and conferred on him the title of “Great Precious Prince of the Faith.”14 This put Phagba in the perfect position to spread Tibetan Buddhism throughout the Mongol empire. The Mongols later compiled Phagpa’s ideas in a book known as White History, which states that “the corner of sacred religion is the Lama, the Lord of Doctrine, the head of power is the Khan, the sovereign of terrestrial power.”15 Later in his life, Phagpa returned to Tibet and established Mongol supremacy over Tibet by ruling in place of the Mongols. Phagpa’s legitimacy to rule gave birth to the Lama-Patron relationship. This unique connection underlines the interdependency of religion and politics in Tibet, which remained in place long after the fall of the Yuan dynasty and the Mongol Empire at large. The Lama-Patron relationship is of great importance in understanding the fusion of religion and politics in Tibet. Isihama emphasizes that, “after the rise of the Qing dynasty, Buddhist government became the diplomatic basis of the Tibetan-Mongol-Manchu relationship.”16 The Lama-Patron relationship refers to a symbolic relationship between a religious figure and a lay patron. The Tibetan word for this connection is choyon, which is an abbreviation of two words: cho which means “that is worthy of being gifts and alms” (a Lama) and yon which means “he who gives to that which is worthy (a patron).”17 It is a difficult concept to comprehend, especially from a western perspective because there is nothing similar in western history. Hevia breaks it down particularly well. He writes: The Lama claimed to command superior spiritual powers. As such he could recognize a lord, including an emperor, as a cakravartin king, instruct him in Buddhism, initiate him into tantric mysteries, and receive offerings from him for sustenance of the sect. The patron, in turn, would be expected to accept a position as inferior, protect the lama, seek his teachings, and promote Buddhism in his domain.18 By unifying the nomadic tribes north of the Great Wall of China, the Qing had established their rule in an area much larger than the former Ming territory. However, a few Western Mongolian tribes, specifically in the Dzungarian Basin, remained independent from the Qing. One such tribe was the Qoshot Mongols, headed by Gushri Khan. Gushri Khan’s relationship with Tibet and specifically, the Fifth the Dalai Lama, shaped the political identity of Tibet for centuries. Around the time the Fifth Dalai Lama was born i.e., 1617, Tibet was in a state of religious and political turmoil.

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Fifth Dalai Lama

There was major hostility between the different schools of Tibetan Buddhism. On one side of this conflict was the Kagyu school. They were allies with the King of Tsang, one of the provinces in Tibet. On the other side of this conflict was the Gelugpa school. The Gelugpa school shared a deep connection with the Mongols. In fact, in 1576, the Prince of the Tumed Mongols invited Sonam Gyatso, a prominent Gelugpa Lama to Mongolia and conferred on him the title of the Dalai Lama, “The All-embracing Lama, the Vajra-holder.”19 From then on, their association only grew stronger, as evidenced by the fact that the reincarnation of Sonam Gyatso, who was to be the fourth Dalai Lama, was born to the chief of Tumed Mongols. Additionally, Rockhill asserts that there were likely more Mongolians recognized as reincarnations of Gelugpa Lamas than Tibetans.20 Sometime around 1630, the King of Tsang rose to power and assumed control over all of Tibet. This was a threat to the very existence of the Gelugpa school of Buddhism since the King of Tsang was an ally of the Kagyu sect. The Fifth Dalai Lama’s regent called upon Gushi Khan, the leader of the Qooshot Mongols and a devout follower of the Gelugpa sect to save their school from persecution. In 1642, Gushi Khan marched his forces into Tibet and defeated the King of Tsang. He then went on to capture all three provinces of Tibet and was declared the ruler of Tibet. Shortly thereafter, Gushi Khan, as a form of respect, transferred his new gained command to the Fifth Dalai Lama. This was the

14 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 2. 15 Thomas Laird, The Story of Tibet. (New York: Groove Press, 2006), 115. 16 Peter Schwieger, The Dalai Lama and the Emperor of China. (New York: Columbia University Press, 2015), 62. 17 Melvyn Goldstein. A History of Modern Tibet 1913-1951. (Berkeley, University of California Press, 1989), 44. 18 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 43. 19 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 5. 20 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 5.

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beginning of the political authority of the Dalai Lama institution in Tibet, which continued until 1959.

21 Peter Schwieger, The Dalai Lama and the Emperor of China. (New York: Columbia University Press, 2015), 62. 22 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 70. 23 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 71. 24 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 71. 25 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 71. 26 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 175. 27 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 81. 28 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 299. 29 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 12. 30 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 154.

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court, received on 1 November 1639, states, “We cannot bear to see suppressed the laws which have come down from ancient times. Neither do we wish that they should be extinguished without transmission to posterity. Therefore, we are The Qing Court’s Perspective The question that looms when it comes to why the sending, especially, envoys to invite you, the high priest, in Qing court invited the Fifth Dalai Lama to Beijing is wheth- order to propagate the growth of the Buddhist Faith and to 26 er the motivation in their invitation was religious or politi- benefit all living beings.” The invitation suggests that the cal. Kam suggests that “the Manchus’ invitation of the Dalai purpose of the trip would be religious; an effort to spread Lama was nothing more than a logical extension of their the teachings of the Buddha and benefit all sentient beings. The third and final aspect of the Qing Court’s redevotion to the faith.”21 This statement attempts to simplify an extremely nuanced motivation. Certainly there were ligious motivation can be seen by the religious duties the religious factors, but stating that the invitation was nothing Dalai Lama performed during his visit. Tuttle notes that more than religious in nature ignores the obvious political the imperial family was actively engaged in making offerperspective. The political motivation seems to bemore cen- ings and receiving teachings from the Dalai Lama. Many high-ranking members of the imperial family even took tral to the Qing invitation. 27 Let me begin by examining the religious motiva- Tantric initiations. The Dalai Lama was even asked by the tion. First, a spiritual connection between the Manchus and Emperor to settle a religious dispute. He notes this in his Tibetans was established even before the declaration of the autobiography: “The emperor sent me Kabala Ama and AkQing Dynasty. In the spring of 1621, a Tibetan Lama, Uluk shan Ama to say that the root of the dispute between the two Darqhan Nangsu, visited Nurhaci at his court. Kam declares Mongolian Lamas was Buddhist religion and I must pass the 28 that Nurhaci’s reception of the Lama was “fulfilling the con- judgement.” These examples signify the religious nature in ventional patron-priest relationship, because Nurhaci, as a the Qing court’s invitation. Nevertheless, the political motivation outweighs the devotee to the religion, not only showed deference to him but also offered him a generous largess including an estate religious motivation. The greatest factor in the Qing court’s with workers.”22 One can contend that Nurhaci was recep- invitation was the western Mongolian tribes. As mentioned tive to the Lama because of political motivations. Perhaps he earlier, the Qing united all of the Mongolian tribes north of wanted to use Tibetan Buddhism as a means to dictate his the Great Wall, but there were still some tribes further west subjects. However, Kam puts this argument at rest, stating, that remained independent. These tribes posed a genuine “Nurhaci’s patronage of the Lama was not politically moti- threat to the newly established Qing Empire, since they could vated since most of the Mongol groups, such as the Uriyangq- potentially unite and form a rival empire. Hence, the Qing ai, Ongninhud, Dorbed, and Jalayid, that came to submit to court sought to use the influence of the Dalai Lama among [Nurhaci] were followers of shamanism, not Tibetan Bud- the Western Mongolian tribes to create a peaceable environdhism.”23 Upon the Lama’s death, the Manchus built a stupa, ment, removing all threats to their power. This is evident in an edict issued by the emperor which states, “in the mida Buddhist shrine that holds the relics dle of the Emperor T’aitsung (1627of high Lamas. The stupa’s inscription 1644), the Khalka had not submitted. claims that the Lama, “gave the abishe“The political motivation Considering the fact that all Tibetans ka or empowerment to the Manchu was more central to the 24 and Mongols obeyed the teachings of Khan (Nurhaci)”. Nurhaci’s interest Qing invitation.” the Lamas, the Dalai Lama was sent in Tibetan Buddhism was passed down for, but before the envoy reached him to his son, Hong Taiji, as evidenced by the Emperor T’aitsung died.”29 By inthe invitation he extended to the Dalai Lama in 1639. Hong Taiji urged the Dalai Lama to visit, “in viting the Dalai Lama to Beijing, Ahmad suggests that the order to propagate the growth of Buddhist Faith and benefit Qing were looking to restore the Lama-Patron relationship 30 all living beings.”25 Evidently, the Qing court’s invitation to that existed between Khublai Khan and Phakpa. By dothe Fifth Dalai Lama was not a spontaneous decision once ing so, they could present themselves to the Mongols as the they came into power. It was an ongoing effort, one that ex- rightful successors to the Yuan and establish their authority over all of the Mongolian tribes. tended back two generations. Another instance that displays the political mo Second, the letter to the Dalai Lama from the Qing tivation in the Qing court’s invitation is the Dalai Lama's

HISTORY

request that the Emperor meet him outside of Beijing. Emperor Shunzhi was not sure if he should adhere to this request. He issued an edict to his court: “If we do not go to meet [the Dalai Lama] after having invited him to come, he may go back to Tibet after having come part of the way, and the consequence will be that the Khalkha will not render their submission.”31 The Emperor’s first concern, if the Dalai Lama returned to Tibet, was that a western Mongolian tribe would not submit to Qing rule. Despite the fact that the Manchus have long been lobbying for this visit, there is no mention of religious teachings. This demonstrates that, at this time, the submission of western Mongolian tribes was the primary concern of the Qing court. The court’s reaction to the Emperor’s dilemma is notable. The Manchu officials recommended that the Emperor abide by the Dalai Lama’s request since, “such an act of extreme condescension would certainly cause the Khalka Mongols to finally submit to the Imperial rule.”32 On the other hand, the Chinese officials recommended that the Emperor not accommodate the Dalai Lama: “being the Lord Paramount of the whole world ought not to go meet the Lama.”33 Initially, the Emperor accepted the advice of his Manchu advisors. He sent a letter to the Dalai Lama, which stated, “you have written to Us that the climate within the borders is bad for your health, and that it is better that we should meet outside the border. We will consequently proceed to Tai-ka and await you.”34 However, in the end, the Emperor remained in the capital, citing unpropitious heavenly signs and his need to be in constant communications with his troops as his reason.35 The differences in opinion between the Manchu officials and the Chinese officials have significant implications. Wills observed that the Qing, “discussed foreign relations not in terms of tribute but in terms of defense.”36 The reaction of the Manchu officials to the Dalai Lama’s request supports this claim. Even though the Emperor did not end up meeting the Dalai Lama outside of Beijing, the fact that he considered it or that his Manchu officials urged him to do so indicates that the Manchu officials were pragmatic thinkers. Unlike the Chinese officials, they were not concerned with the protocols based on the traditional Sino-centric view of the world. From the Sino-centric perspective, the Lord of all under Heaven should not even consider the Dalai Lama’s request. The belief is that the purpose of any guest to the court of the Emperor of China is to present tribute. The Emperor’s Manchu advisors calculated that breaking the protocol in order to fulfill the Dalai Lama’s request would be advantageous. They were willing to overlook the rigors of the tribute system model to achieve a larger goal i.e., to

bring the western Mongolian tribes under Qing rule. Moreover, they were. This clearly aligns with the idea that the Qing were masters at adapting their ideology of rulership and administrative structure according to their benefit. This conclusion corroborates the work of Rawski and scholars of the New Qing history. As for the formal audience, the Chinese records are nowhere near as detailed as the Dalai Lama’s autobiography. Ahmad states that, “only such facts have been recorded as occurred within the official range of activities.”37 After the Emperor decided not to meet the Dalai Lama outside of Beijing, he sent Shisai, his elder brother, and Jirgalang, his uncle and former regent, to welcome the Dalai Lama. Jirgalang’s presence is notable since, at the time of the Dalai Lama’s visit, he was probably the most powerful figure in the Qing court.38 These two members of the imperial family accompanied the Dalai Lama on his way. According to the “Veritable Records of the Qing Dynasty,” the Dalai Lama met the Emperor in the South Park on 14 January 1653. The Emperor permitted the Dalai Lama to sit in his presence and gave a banquet to honor him. The Dalai Lama brought products from Tibet and presented them to the Emperor. It is explicitly mentioned that the Dalai Lama brought horses as tribute. The Emperor accepted the Dalai Lama’s tribute.39 Upon the Dalai Lama’s departure, the “Veritable Records,” notes that the Emperor gave a banquet and presented gifts such as saddles, gold, silver, and jade to the Dalai Lama.40 As expected, the court documents emphasize the presents brought to the Court and presents given by the Court. However, the Dalai Lama’s autobiography allows us to further visualize this visit.

The Dalai Lama’s Perspective

It is easy to assume that the Dalai Lama’s motivation for accepting the invitation to visit Beijing was political. The Dalai Lama had just gained both spiritual and temporal power over all of Tibet. By travelling to Beijing, he had the perfect opportunity to establish an alliance with a powerful neighbor who could assist him when necessary. Yet upon closer examination, it is apparent that the Dalai Lama’s motivation for accepting the Qing court’s invitation was primarily religious. Tuttle writes, “the visit of Beijing must be seen in the context of missionary activity, rather than strictly as a matter of political expediency.”41 As a Buddhist monk and teacher, the Dalai Lama’s primary reason for this visit was to spread the teachings of the Buddha. The Dalai lama believed that he shared a religious

31 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 12. 32 W.W. Rockhill. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperors of China. (Delhi: Indraprastha Press, 1998), 11. 33 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 168. 34 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 170. 35 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 172. 36 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 14. 37 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 21. 38 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 82 39 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 177. 40 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 181. 41 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 66.

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connection to the Manchu Emperor. This is evident in his autobiography. He writes about a prophecy that a high Tibetan Lama, Yolmo Trulku sent him when Tibet was crippled with religious warfare. The prophecy said: “The emanation of Jampal will be in Ü. If he does not come across with sudden impediments, He will tame Tibet, China, and Mongolia.”42 The Dalai Lama determines that this emanation of Jampal, a Tibetan Buddhist deity, that Yolmo Trulku prophesized to rule over such vast lands must be the Manchu Emperor: “it occurred to me that Yolmo Trulku probably thought of me as having connection with Jamyang (the Manchu Emperor).”43 It is this spiritual connection that inspired the Dalai Lama to undertake the difficult journey to the Qing court. The Dalai Lama believed, as Ahmad notes, that the Manchu emperor was a possible Dharma King who would rule according to Buddhist values and act as Tibet’s patron.44 Similar to Phagpa four centuries ago, the Dalai Lama saw an opportunity to expand the influence of Buddhism and the Gelugpas with the help of a dominant patron.

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Fifth Dalai Lama and Emperor Shunzhi

42 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 223. 43 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 223. 44 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 159. 45 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 73. 46 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 266. 47 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 76. 48 Gray Tuttle. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 74. 49 Zahiruddin Ahmad, Sino-Tibetan Relations in the Seventeenth Century. (Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente, 1970), 181. 50 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 39.

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In making this journey, the Dalai lama was not simply focused on the end goal of reaching Beijing and spreading Buddhism. Instead, the prospect of teaching Buddhism to Mongolians along the way played a vital role in his decision. When the Dalai Lama received the invitation, he was in the midst of writing the biography of the Third Dalai Lama. Tuttle points out that, “revisiting the events of his predecessor may have further inspired him to retrace his steps and recreate old bonds that may have weakened, especially with the Ordos and Tumed Mongols.”45 On his way to Beijing, he took time to teach Buddhism to Tibetans, Mongolians, and

Chinese from all walks of life. He writes, “Mongols, the Hor people and nomads of the local area came to meet me and I gave teachings for each group as they wished.”46 The Dalai Lama provides detailed records about his encounters with different groups and the teachings that he gave. The number of people who received teachings and offered presents to the Dalai Lama is notable. Tuttle provides a break down: In Kokonor, at least four thousand Mongols came to greet the Dalai Lama, of which three-fourths were initiated and therefore made donations. In the Ordos some twenty thousand Mongols made offerings with about one-third taking initiations from the Dalai Lama. Among the Tumed, some forty-one hundred Mongols came to see the Dalai Lama and again some three-quarters were blessed. Only some six hundred officials made offerings and received initiations. The vast majority of the people he met in and around the capital, some twelve thousand in all, also seemed to have been Mongols, though it is clear that Tibetans, Manchus and Chinese were also counted among these.47 Overall, the Dalai Lama’s autobiography suggests that he gave teachings to an estimated forty thousand Mongols, who represented the most numerous and economically significant of all of the different groups he taught.48 This concurs with the notion that the the western Mongolian tribes and their interest in Tibetan Buddhism were strongest causes of the Qing court’s motivation in inviting the Dalai Lama and the Dalai Lama’s motivation in accepting the invitation. As previously mentioned, the Dalai Lama met members of the imperial family who were sent by the Emperor to welcome him outside Beijing. His account in his autobiography upon meeting Jirgalang, the Emperor’s uncle is noteworthy. He states that Jirgalang, “appeared with an entourage of 3000 riders, and a striking display of sword, umbrella, banner, flag, music, etc.... it was a sign that I was the legal King (of Tibet) of whom there was not the like in Tibet.”49 The Dalai Lama saw himself as the legitimate ruler of Tibet, and the Emperor treated him as such, by sending arguably the most powerful figure in the Qing Court beyond the Great Wall to receive him. Furthermore, Hevia demonstrates why the Dalai Lama was not incorrect in his belief: “The Dalai Lama invested, entitled, and provided seals for Mongol Khans, received and dispatched disputes between the Khans, and like emperors and Khans, received and dispatched embassies, commanded populations – in some cases, even armies.”50

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The Dalai Lama’s autobiography provides great de- the Emperor thought that it was more important to please tail of his formal audience with Emperor Shunzhi. Compar- the Dalai Lama so that he would help them in bringing the ing the account of this visit to the traditional protocols of western Mongolian tribes under their rule. Regardless, this a visit by a tributary state is rather stimulating. Jochim de- pragmatic approach demonstrates that the Manchu Emperscribes the ceremonial audience in the traditional Sino-cen- ors were different from other Chinese Emperors. Instead of tric view as, “an event that revered, and reified, the entire holding on to the Sino-centric view of the world, they drew pattern of relationships built around the imperial person, a on the influence of the Dalai Lama and adapted Buddhist pattern of hierarchical order superimposed upon a well-or- ideology in order to expand their empire. chestrated and coherent oneness.”51 In other words, there were strict rules that had to be followed, which cemented the Conclusion Emperor’s status as the Lord of all under Heaven. However, In sum, the Fifth Dalai Lama’s visit to Beijing demonthe Dalai Lama’s account of his audience does not follow this strates the pragmatism of the Manchu Emperor and his offiprocedure. The Dalai Lama writes that, “the Emperor de- cials. Wills notes that the Qing’s, “relations with Europeans... scended from his throne and came forward to the range of did not fit the rigors of the tribute-system model.”57 In this ten arm spans. [The Emperor]held [the Dalai Lama’s] hands same manner, the Qing’s relations with the Tibetans do not and through an interpreter enquired about [his] health.”52 fit into the traditional tribute-system model, at least during Furthermore, “when tea was served, he said, ‘You drink the the time of the Fifth Dalai Lama. This is demonstrated by tea first.’ I replied: ‘That would not be right.’ He said: ‘Let us the Emperor’s treatment of the Dalai Lama at his court. The drink it at the same time then.’”53 It is obvious that the Da- main goal of their invitation was to use the influence of the lai Lama was not just another guest at the Qing court. The Dalai Lama to bring the western Mongolian tribes under Emperor went out of his way to pay his respect, ignoring the their rule. In order to do so, they had to ignore the traditraditional protocols of the tribute system. tional Sino-centric view of the world which held that the The Dalai Lama appears to have spent approximate- Emperor was the Lord of all under Heaven. They realized ly two months as a guest of the Qing Court. Throughout his that they could adopt the Lama-Patron relationship which stay, he gave teachings to members of the imperial family would expand their empire. The main reason why this visand the noble class. He even gave teachings to the Emperor it had a successful outcome, both for the Qing Court and himself, particularly the Jenang of Drolkar Chendunma and the Dalai Lama, was the pragmatic and respectful approach instructions in the guruyoga practice.54 In turn, the Emper- from both sides thatallowed for a mutually beneficial relaor showered the Dalai Lama with generous gifts such as a tionship between the two. This is evidenced by the period “rosary of a hundred beads of pearls,” in which each pearl of peace and prosperity both parties enjoyed for centuries. was as big as the tip of a finger.55 Moreover, the Qing court The Qing Dynasty went on to become one of the largest and hosted numerous banquets and receptions in honor of the most powerful empires. Hevia notes that, “it also seems sigDalai Lama. In these events, the Dalai Lama received vast nificant that emperors received consecrations from Tibetan amounts of presents from members of the noble class such Buddhist lamas and were willing to accept names and titles as jewelry, clothes, and such as “cakravartin king” horses. Whenever the and the “bodhisattva ManDalai Lama and the "Instead of holding on the Sino-centric view jushri”.58 This supports the Emperor were present New Qing History school of the world, [Manchu Emperors] drew on the at the same event, the of thought. Rawski’s claim influence of the Dalai Lama and adapted BudEmperor made sure to that the Qing, “drew on dhist ideology in order to expand their empire." show his respect. One multiple sources and such account is recordadapted ideologies of ruled by the Dalai Lama: ership and administrative “the [Emperor] entered from the back door and stood on a structures,” is proven accurate when analyzing the Qing Emgolden throne that was very large and the height of a man’s pire’s relationship with Tibet and the Fifth Dalai Lama. waist... before he sat down, he stood there and sent Askhan Ama to tell me that I should sit on my throne at the same time as he sat on his stool.”56 Perhaps the Emperor performed this gesture out of respect for his spiritual teacher or perhaps 51 Christian Jochim, “The Imperial Audience Ceremonies of the Ch’ing Dynasty.” SSRC Bulletin, no. 7 (1979): 96. 52 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 294. 53 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 294. 54 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 301. 55 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 302. 56 Samten Karmay, The Illusive Play: The Autobiography of the Fifth Dalai Lama. (Chicago: Serindia Publications, 2014), 297. 57 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 13. 58 James Hevia, Cherishing Men from Afar. (Durham and London: Duke University Press, 1995), 40.

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References:

Ahmad, Zahiruddin. Sino-Tibetan Relations in the Seventeenth Century. Roma: Istituto Italiano Per Il Medio Ed Estremo Oriente. 1970. Goldstein, Melvyn. A History of Modern Tibet 1913-1951. Berkeley: Uni versity of California Press. 1989. Hevia, James. Cherishing Men from Afar. Durham and London: Duke University Press. 1995. Jochim, Christian. “The Imperial Audience Ceremonies of the Ch’ing Dy nasty.” SSRC Bulletin no. 7 (1979): 88-103. Karmay, Samten. The Illusive Play, The Autobiography of the Fifth Dalai Lama. Chicago: Serindia Publications. 2014. Laird, Thomas. The Story of Tibet. New York: Groove Press. 2006. Rawski, Evelyn. “Presidential Address: Reenvisioning the Qing: The Sig nificance of the Qing Period in Chinese History.” The Journal of Asian Studies 55, no. 4 (1996): 829-850. Rockhill, W.W. The Dalai Lamas of Lhasa and Their Relations with the Manchu Emperor of China. Delhi: Indraprastha Press. 1998. Schwieger, Peter. The Dalai Lama and the Emperor of China. New York: Columbia University Press. 2015. Spence, Jonathan. The Search for Modern China. New York: W.W. Norton & Company, 2013. Tuttle, Gray. “A Tibetan Buddhist Mission to the East: The Fifth Dalai Lama’s Journey to Beijing, 1652-1653.” Brill’s Tibetan Studies Library 10, no. 3 (2006): 65-87.

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