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EDUCATIONAL TRAINING ON SUCCINYLCHOLINE Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 20202 The Effects of Educational Training of Succinylcholine Dosing on Myalgia Pain Tiffany Cabeca Marian University Leighton School of Nursing Chair: Dr. Sara Franco _________________________ (Signature) (Date) Committee member: Dr. Beth Townsend _________________________ (Signature) (Date) Date of Submission: November 5, 2021 1 EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 2 Table of Contents Abstract ............................................................................................................. ...3 Introduction ........................................................................................................................ 4 Background .............................................................................................................. 4 Problem Statement ................................................................................................... 6 Organizational Gap Analysis of Project Site ....................................................... 6 Review of the Literature ...................................................................................................... 6 Theoretical Framework......10 Goals/Objectives/Expected Outcomes...12 Project Design/Methods...... ..12 Project Site and Population.......................................................................... ..13 Measurement Instrument(s) .................................................................................. 13 Data Collection Procedure .................................................................................... 14 Ethical Considerations/Protection of Human Subjects .14 Data Analysis and Results......15 Discussion...18 Conclusion ........................................................................................................................ 19 References ......................................................................................................................... 21 Appendices Appendix A............................................................................................................ 24 Appendix B ............................................................................................................ 25 Appendix C.27 Appendix D.28 EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 3 Abstract Succinylcholine is a well-known depolarizing muscle relaxant used for endotracheal intubation in the perioperative setting. Due to its depolarizing properties, many patients complain of myalgia pain postoperatively. Patients describe this muscle pain as muscle stiffness or soreness, similar to what one feels after extraneous physical activity. Evidence-based research has shown that increasing the dose of succinylcholine to 1.5mg/kg can help reduce myalgia pain in patients. The importance of adequate pain control during the postoperative period facilitates early recovery and a better perioperative experience. Poor postoperative pain control can lead to decreased patient satisfaction and increased respiratory complications. The purpose of this quality improvement project is to provide formal education on how certified registered nurse anesthetists (CRNAs) can lessen myalgia pain through an online learning workshop. The goal is to educate CRNAs and assess the likelihood of a practice change. This was assessed through a quantitative pre-and postsurvey. The survey asked Likert-based questions based on the pathophysiology, impact/prevalence, and the dose given in practice. The online workshop consisted of three modules. The results showed a significant difference Z= -1.0, p < .05, where the post-survey showed that CRNAs were willing to change their practice. Participants were able to complete the module over one month in a self-paced manner. Some of the limitations encountered were technical difficulties, sample bias, and small sample size. The educational module results displayed an increase in willingness to increase their dose and the participants' knowledge base on this commonly used muscle relaxant. Keywords: succinylcholine myalgia, succinylcholine dose of myalgia, succinylcholine myalgia in outpatients, effect of post-anesthesia myalgia, post-anesthesia myalgia complications, effect of postoperative myalgia on patient recovery, and succinylcholine induced fasciculations. EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 4 The Effects of Educational Training of Succinylcholine Dosing on Myalgia Pain The postoperative period can be stressful for many patients as they worry about the associated complications of every surgical procedure. Not only must patients overcome surgical pain resulting from their incisions, but they may also experience side effects from many anesthetic medications. A prominent side effect of the depolarizing muscle relaxer succinylcholine is myalgia. Myalgia is described as muscle stiffness or soreness, similar to how one would feel after exercising (Wong & Chung, 2000). The pain can range from mild to severe and sometimes debilitating. It can present itself with varying degrees of characteristics that can prevent patients from participating in their daily activities. If the pain is severe, it can lead to fatigue and depression (Southern Pain and Neurological, 2020). The importance of adequate pain control during the postoperative period facilitates patients to participate in physical therapy. Poor postoperative pain control can lead to increased morbidity, impaired function, longer recovery times, respiratory complications, prolonged opioid use, and increased medical costs (Gan, 2017). Due to these negative consequences, minimizing myalgia pain is imperative for the success of patient recovery. Certified registered nurse anesthetists (CRNAs) play an active role in preventing myalgia pain, as increasing the dosage can help lessen the pain patients experience. This project aims to educate CRNAs on the benefit of using higher dose succinylcholine to lessen succinylcholine-induced myalgia pain. Background Succinylcholine is the only depolarizing muscle relaxant licensed for use in the United States, thus rendering it a popular drug for endotracheal intubation in the perioperative setting. The drug's mechanism of action is classified as an agonist-antagonist, where the drug's molecule binds to the motor endplate causing the sarcomere to contract. These contractions are known as fasciculations. Once the drug is bound, it provides paralysis by preventing acetylcholine molecules from binding to the motor endplate and initiating another response. The mechanism of action EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 5 between myalgia and fasciculations is not well defined. This theory is due to the asynchronous activity of muscle fibers, which cause filaments to rupture. The contraction occurs in synchrony when administering a higher dose, reducing damage to muscle spindles (Wong & Chung, 2000). Further research on this phenomenon is needed to provide a better understanding of succinylcholine-induced myalgia pain. The asynchrony of muscle fibers' activity causes muscle pain in the subcostal region, trunk, neck, upper abdominal muscles, and shoulders (Nagelhout & Elisha, 2018). Myalgia pain incidence can range from 50% to 90% in surgical patients and lasts up to ten days (Shafy et al., 2018). Patients describe experiencing the worst pain during the first 24-hour period; however, severity may range from individual to individual. Those at greatest risk of experiencing myalgia are nonpregnant females, those who do not participate in muscular activity, and those who undergo minor operations (Nagelhout & Elisha, 2018; Wong & Chung, 2000). Studies have shown ways to reduce myalgia are by pretreating with 10% of the ED95 (effective dose required to achieve the desired effect in 95% of the population) of a nondepolarizing neuromuscular blocker (e.g., Rocuronium), nonsteroidal inflammatory drugs (NSAIDs), and sodium channel blockers (e.g., Lidocaine). While NSAIDs and sodium channel blockers have been shown to provide a therapeutic effect, the nondepolarizing agent poses a risk of respiratory depression in patients. A change in practice is needed to help decrease postoperative myalgia pain through safer practices. The lack of research and the accompanying risks of succinylcholine administration has prevented providers from delivering higher doses. Many anesthesia providers may administer a lower dose due to the uncertainty of the higher doses effects on potassium levels, intragastric, intraocular, and intracranial pressures (Nagelhout & Elisha, 2018; Wong & Chung, 2000). Provider comfortability may also pose a challenge to this change in practice. Problem Statement EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 6 Anesthetists are well aware that succinylcholine use is affiliated with postoperative myalgia in surgical patients. Not only does it have a high incidental prevalence, but the risk is increased in specific populations. The importance of reducing overall pain during recovery is essential to the patient's overall rehabilitation. Though anesthesia providers cannot control the severity of surgical pain, succinylcholine-induced myalgia is a modifiable anesthesia practice that providers can adjust in the intraoperative period. The goal is to provide formal education on how CRNAs can lessen myalgia pain through higher dosing of succinylcholine. The approach taken was a prospective evidence-based online learning module. CRNAs completed the learning module, along with a pre-and post-test. The resulting post-test scores were compared to the pre-test scores. Comparing scores between the tests will assess the willingness of a practice change. Gap Analysis There is no universal best practice guideline for the dose of succinylcholine. The acceptable range for succinylcholine administration is .5-1.5mg/kg (Nagelhout & Elisha, 2018). The current practice at a 218-bed hospital in a southern state uses the 1mg/kg dosing. The quality improvement project was examined utilizing the change theory as an evidence-based practice framework. The learning module was distributed through e-mail and completed through an online learning system, Canvas. Research has suggested that using a higher dose of succinylcholine will reduce postoperative myalgia incidence (Schreiber et al., 2005). By comparing pre-and post-test scores, the results will reflect whether CRNAs are more willing to use higher dose succinylcholine. Literature Review Search Methodology A review of all published studies conducted between 1950 and 2020 was performed using PubMed and Google Scholar. Excluding any language restrictions, the search strategy consisted of keywords that included: succinylcholine myalgia, succinylcholine dose of myalgia, EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 7 succinylcholine myalgia in outpatients, effect of post-anesthesia myalgia, post-anesthesia myalgia complications, effect of postoperative myalgia on patient recovery, and succinylcholine induced fasciculations. The Boolean phrase used in this literature review was fasciculation and myalgia. Exclusion criteria for articles were those published in a language other than English, participants under 18, and those receiving pre-medications. Inclusion criteria included articles published in English, patients receiving succinylcholine, and patients over 18 years old. Fortyfour thousand one hundred seventy-two journals were found using the keywords. Of those identified, journals that met the exclusion criteria were eliminated. Of those that met the inclusion criteria, 124 abstracts were examined, and 73 of those records were excluded because they did not assess myalgia according to different doses of succinylcholine or did not provide adequate information on myalgia and recovery. Fifty-one full-text articles were assessed for eligibility. The reference lists of the potentially relevant papers were also reviewed by hand to identify additional articles. Seventeen journals focusing on different doses of succinylcholine and myalgia effects were used for the literature review. Postoperative Myalgia Pain The incidence of succinylcholine-induced myalgia is a phenomenon that is frequently encountered in the postoperative period. Researchers agree that there is a causative relationship between succinylcholine and postoperative myalgia. Myalgia is defined as muscle stiffness or soreness similar to how one would feel after physical activity, specifically found in the neck, shoulders, back, and abdomen (Schreiber et al., 2005; Shafy et al., 2019; Jain et al., 2019). The majority of the studies have determined this is a minor side effect of the drug and is often an unfortunate consequence of minor surgery among patients (Findlay & Spittal, 1996; Schreiber et al., 2005; Wong & Chung, 2000; Stewart et al., 1991; Schreiber et al., 2003). It also has been shown that the prevalence of symptoms varies widely from 1.5% to 89%, with 50% being the most probable (Findlay & Spittal, EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 8 1996; Nimmo et al., 1995; Wong & Chung, 2000; Shafy et al., 2019). The wide range is due to multifactorial risk factors. The Impact of Myalgia Pain As a result of the undesirable and unwanted side effects, anesthesia providers tend to avoid succinylcholine administration unless necessary, rendering it among the top 30 causes of anesthesia side effects (Macario et al., 1999). Not only do anesthesia providers acknowledge the need to decrease succinylcholine side effects, but when patients were asked if avoiding postoperative myalgia is important, 89% of patients concurred and would even pay an out of pocket fee to avoid this experience (Macario et al., 1999; Allen et al., 2007). In addition to the short-term debilitation feeling, two of the seventeen reports described postoperative myalgia as unacceptable in modern practice (Jain et al., 2019; Wong & Chung, 2000). A case report examining the etiology and prevention of myalgia stated that the severity of the condition could increase to levels that interfere with normal daily living activities, such as returning to work or school (Shafy et al., 2019). Since ambulation increases the possibility of myalgia and its intensity, ambulatory patients are at the highest risk for these complications (Nasseri & Arvien, 2016). Conversely, some researchers suggest that succinylcholine may not be appropriate for ambulatory surgical patients since it may impede the return to regular activity (Mikat-Stevens et al., 1997). Evidence among various reports proves conflicting, as seen in this analysis. The combination of incisional pain and muscle stiffness reduces ambulation after surgery. A report investigating the effect of activity found that patients were more active on the second day than the first day after surgery. On the first day, 47% of patients were up in a chair, 21% had limited mobility, and 32% had unrestricted mobility (Oxorn et al., 1992). Comparably, an analysis exploring the limitations to self-care in ambulatory patients stated that myalgia might be more severe than incisional pain. Patients reported back pain and the inability to perform EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 9 activities of daily living such as preparing food, walking to the restroom, and washing their hair to be the most debilitating after surgery. Because myalgia may be delayed and last up to ten days, self-care deficits can lead to anxiety and frustration, further delaying recovery (Lupien et al., 2000). Lastly, a cost-identification analysis reported that the amount of money spent treating myalgia pain exceeds the cost of one dose of succinylcholine. Similarly, another study examining the same subject matter found that the cost of a succinylcholine dose from a patient's perspective equals the drug's acquisition cost plus the cost of its adverse effects (Allen et al., 2007; Dexter et al., 2001). The Impact of Higher Doses of Succinylcholine on Myalgia Pain Four of seventeen studies showed a decrease in postoperative myalgia when providers administered a higher dose of succinylcholine. The hallmark study by Waters and Mapleson (1971) discovered that the amount of muscle pain should show an inverse relationship to the dose of succinylcholine administered. It explained that those who received doses between 100mg and 200mg had less pain than those who received a lower dose. Similarly, a randomized control trial looking at the influence between .5mg/kg, 1.5mg/kg, and 3mg/kg on myalgia showed that those who received the .5mg/kg and 3mg/kg dose had an overall incidence of 40% and 50%, respectively, while the 1.5mg/kg dose had an incidence of 70% (McLoughlin et al., 1994). Wong and Chung (2000) also reported that higher doses of succinylcholine resulted in reduced postoperative myalgia pain. Contrary to these studies, a meta-analysis of randomized trials suggested evidence to show less myalgia with the 1.5mg/kg dose compared to the 1mg/kg. The average incidence of myalgia was 44.6% with the higher dose compared to 62.8% with the lower dose (Schreiber et al., 2005). There is ambiguity about whether the higher dose is determined per kilogram or total overall dose, although all four sources agreed that higher doses would lessen myalgia pain. EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 10 The Impact of Lower Doses of Succinylcholine on Myalgia Pain While four studies expressed a lower incidence of myalgia with higher doses, three reports described the opposite. In a double-blind study of 67 participants, succinylcholineassociated muscle pain was more common in the group who received the 1.5mg/kg dose on induction (p < 0.05) than the 0.5mg/kg group (Stewart et al., 1991). A similar study found no significant difference in myalgia pain when lower doses of succinylcholine were administered (Nimmo et al., 1995). Myalgia incidence was 41% in the 0.5mg/kg category, compared to 20% in those who received 0.25mg/kg (Findlay & Spittal, 1996). Although studies showed these doses lowered myalgia pain, they did not provide adequate relaxation for endotracheal intubation. Pathophysiology of Succinylcholine Induced Myalgia The mechanism of succinylcholine-induced myalgia remains unknown. There have been multiple theories behind this phenomenon; however, the hypothesis that the pain results from muscle fibers contracting asynchronously is the most popular among researchers. Five out of the seventeen articles explained this as the primary mechanism of action, along with other modalities (Nimmo et al., 1995; McLoughlin et al., 1994; Wong & Chung, 2000; Waters & Mapleson, 1971; Schreiber et al., 2005). Investigations researching biochemical markers of muscle damage did not correlate with myalgia incidence (Schreiber et al., 2005; Wong & Chung, 2000). Among the other research findings, the following were described as probable causes: lactic acid buildup, the release of free fatty acids, activation and degradation of phospholipids, and inflammation (Wong & Chung, 2000; Nimmo et al., 1995; Schreiber et al., 2003; Jain et al., 2019). Though many theories have been explored, the exact reason remains unknown. Theoretical Framework The framework used to guide this evidence-based quality improvement project is the change theory of nursing developed by Kurt Lewin (Nursing Theory, 2020). The framework is well EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 11 suited for the research question because it encourages professionals to facilitate change. It was created as a three-step model where nurses are guided to let go of old patterns, change thoughts or behaviors, and establish new habits. For a visual depiction of the change theory, reference Appendix A. The change theory framework incorporates three distinct stages: unfreezing, change, and refreezing. The initial stage or unfreezing involves educating others to let go of an old pattern viewed as counterproductive or inefficient. A barrier often encountered in this stage is individual resistance ad conformity. The change stage, also known as the movement stage, encompasses a change in thought or behavior that leads to productivity. Lastly, the refreezing stage embraces the implemented change as routine so that it becomes standard practice. Alignment between the Change Theory and Project Components Step 1: Unfreezing The common practice among CRNAs at a southern hospital is to use the 1mg/kg dose of succinylcholine. Lower doses of this paralytic increase the incidence of myalgia. Thus, this quality improvement project aims to educate CRNAs to let go of this old pattern and use the higher dose of the paralytic agent. Step 2: Change This DNP (Doctorate of Nursing Practice) project aims to inform CRNAs on the benefit of using higher dose succinylcholine by educating them on the pathophysiology behind the fasciculation theory, the impact myalgias have on patients, and evidence-based research on myalgia outcomes when using the opposing doses. Through proper education, the goal is to elicit a practice change in behavior. Step 3: Refreeze EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 12 The goal in this final stage is for CRNAs to implement using a higher concentration of succinylcholine, educate others, and for this new change to become the accepted standard in their practice. Goals, Objectives, and Expected Outcomes This quality improvement project was to provide formal education on how CRNAs can lessen myalgia pain through higher dosing of succinylcholine. This will not require a change in the providers anesthetic plan. The principal investigator will develop and implement an evidencebased online learning module to educate CRNAs and assess the likelihood of a practice change. The objective is to have the CRNAs complete the online learning module over one month. Assessing the likelihood of a practice change was measured through a quantitative pre-and poststudy survey. No identifying information was obtained or reported. Participation in this study was voluntary, and all participants and their answers will remain anonymous. Anonymity was maintained using Qualtrics, an online survey software. The expected outcome is to have CRNAs willing to administer a higher dose of succinylcholine, as evidenced by their responses on the postsurvey. Project Design/Methods The quality improvement practice design is an educational intervention. This design is an educational intervention because the project aims to educate CRNAs on how higher doses of succinylcholine can result in less postoperative myalgia pain for patients. It was an online workshop that used evidence-based research to promote best practice guidelines. It included a presurvey, three educational training modules, and a post-survey. The pre-and post-surveys evaluated their knowledge and confidence levels on myalgia and succinylcholine facts. In addition, it inquired about their willingness to change their practice before and after the educational workshop (Appendix B). EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 13 The succinylcholine-induced myalgia pain educational workshop was made available to CRNAs via Canvas. The first module contained the pre-survey, a review and video of the pathophysiology of succinylcholine, a visual and explanation of the fasciculation theory, and a reflection discussion forum. The topic for module two was understanding the impact and prevalence of fasciculations on surgical patients. This module included two reading assignments and a discussion board. The third and last module focused on using evidence-based research to educate the participants on the benefit of using higher dose succinylcholine to prevent myalgia pain and contained the post-survey. The post-survey contained the same questions as the pre-survey. Reminder e-mails were sent out weekly to increase compliance levels. Once surveys have been completed, a statistical analysis was performed to evaluate whether the educational module helped elicit a practice change. Project Site and Population The project took place online via e-mail to CRNAs employed at hospital A, a 218-bed facility in a southern state. The only necessary resources were computer and internet access. These CRNAs were chosen because succinylcholine is the main paralytic used in their practice. Exclusion criteria were those who did not use succinylcholine daily. Measurement Instrument In order to measure the outcomes of this DNP project, the following instrument was used: a self-created pre-and post-survey was issued to all participants (Appendix B). Demographic information collected in the surveys included age, years of experience, hospital setting, level of education, gender, and the dose of succinylcholine given. Both surveys assessed their knowledge and confidence levels on myalgia and succinylcholine facts. It also inquired about their willingness to change their practice before and after the educational workshop. Responses were measured using a five-point Likert scale designed as follows: (1) Strongly Disagree (2) Slightly Disagree (3) Undecided: neither agree or disagree with the statement (4) Slightly Agree (5) Strongly Agree, or EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 14 (1) Extremely unconfident (2) Somewhat unconfident (3) Neither confident or unconfident (4) Somewhat confident (5) Extremely confident, and (1) Extremely unwilling (2) Somewhat unwilling (3) Neither willing or unwilling (4) Somewhat willing (5) Extremely willing. Data Collection Procedure Pre-intervention An educational module was created using the university's learning management system, followed by a pre-and post-survey. The primary investigator sent the chief CRNA an e-mail with the link to the Canvas module. The chief CRNA forwarded the link to all the CRNAs on the hospitals roster. The link was utilized to invite the participants to the workshop. The workshop was available to the CRNAs for four weeks. Intervention To begin the educational module, participants were first required to create an account and complete the pre-survey available via Qualtrics located during the first module. Consent was obtained during the pre-survey. Upon completion of the pre-survey, participants were able to access the three modules. The course was able to be completed in one sitting or throughout the time allotted of one month. Participants watched educational videos, reflected on prompted questions, and read reading assignments. The chief CRNA sent weekly e-mails to increase compliance levels. Post-intervention Once all three modules were completed, the participants took the post- survey. Upon conclusion of the four weeks, data was collected from Qualtrics, and an analysis using SPSS software was executed. Ethical Considerations/Protection of Human Subjects The Marian Internal Review Board (IRB) approval was obtained prior to initiating the DNP project. This research project provided minimal risk to participants since it did not entail EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 15 biospecimens, vulnerable populations, or address sensitive subject matters. In addition, it did not involve more than minimal risk with concern to mental/physical health. This project did not use patients or protected personal health information in the study group. Due to this, exemption through category two was sought and established (Appendix C). Category two consists of surveys where the obtained information remains unidentifiable and provides minimal risk to subjects. No personal identifiers were obtained in this research project, and the research results were kept in a password-protected computer in the investigator's possession. Participants filled out a pre-survey before starting the course. Before accessing the survey, information regarding the survey and research project was given, and consent was obtained (Appendix D). Participants were allowed to stop at any time. Data Analysis and Results Surveys were sent to 15 CRNAs with five responses for a 33.3% completion rate. Of the five that completed the module, two were female (40%), and three were male (60%). The average age for the group was 56, with 47 being the minimum and 64 the maximum. Among the five participants, one had their certificate in anesthesia (20%), while the rest had their master's degree (80%). This group's average years of experience was 24.6, with 12 being the minimum and 32 being the maximum. Regarding survey question number six, What dose of succinylcholine do you give? 60%, or three participants, reported that they used the 1mg/kg dose. Overall, all participants were willing to change their practice, as evidenced by the survey results. Some participants were more likely than others. Out of those three, the pre-test showed two (67%) said they were somewhat willing to change their practice, while the other (33%) said they were extremely willing. The other two participants used the 1.25mg/kg dose, and pre-survey results showed they were somewhat willing to increase their dose to 1.5mg/kg. The post-survey results showed an increase in the extremely willing category of 20%. The data was analyzed by completing a Wilcoxon test. The Wilcoxon test was performed using SPSS EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 16 statistical analysis software. It compared the means of the two surveys to determine whether the educational module elicited a practice change. The test examined the results of the pre-test and post-test surveys. A significant difference was found in the results Z = -1.0, p <.05. The post-test was better than the pre-test results; thus, the educational module did help elicit a practice change. The bar graph in Figure 1 illustrates an increase of one individual in the extremely willing category in the post-test from the pre-test. Module one focused on the pathophysiology and the fasciculation theory. CRNAs were asked to rate their confidence levels before and after the learning module based on these topics. The surveys asked the participants to assess their knowledge on the theory behind using higher dose succinylcholine on preventing myalgia. Confidence levels significantly increased in this category. The pre-test showed that most CRNAs (60%) felt somewhat unconfident in their knowledge behind this theory. After the learning intervention, 60% felt extremely confident. The bar graph in Figure 2 indicates a significant difference found in the results (Z= -1.6, p < .05). The post-test had an increase of 40% in the extremely confident section. Additionally, pre-test findings suggested that 60% of participants felt somewhat confident on the mechanism of action by which succinylcholine produces myalgia. The rest of the participants felt neither confident or unconfident (20%) or extremely confident (20%). Upon completing the learning module, 60% felt extremely confident, while 40% felt somewhat confident. The second module assessed their knowledge of the impact and prevalence of fasciculations on surgical patients. Participants were asked to agree or disagree with statements on these topics on a Likert-based scale. The assumption is that CRNAs would have a solid foundation on the impact and prevalence of succinylcholine-induced myalgia pain on their patients. The pre-test results indicated otherwise for all questions asked. When asked if ambulatory patients were at a higher EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 17 risk for myalgia pain than inpatients, the pre-test results showed mixed outcomes: 40% stated they slightly agreed, 20% were undecided, slightly degreed, and strongly disagreed. Furthermore, when asked if myalgia interfered with activities of daily living, 40% were undecided or slightly agreed, and one participant or 20% strongly agreed with this statement. Likewise, when asked if myalgia pain can last up to ten days, pre-test survey outcomes revealed that 60% were undecided, 20% slightly disagreed or strongly agreed. Figure 3 demonstrates a visual depiction of the CRNAs answers in the pre and post-survey to the questions mentioned above. Upon concluding the learning module, there was an increase among all three categories. Figure 1 Result of Wilcoxon Test: How likely are you to increase your dose to 1.5mg/kg? Figure 2 Result of Wilcoxon Test: How confident do you feel on the theory behind using higher dose succinylcholine? EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 18 Figure 3 Result of impact and prevalence questions. Discussion The study had a few strengths. They include ease of access to the modules from home and the ability to complete them in a self-guided/self-paced method throughout the month. Participant comfortability allows participants to delve into the module without external pressures. Likewise, the modules were arranged in an organized way with relatable information and evidence-based research. The information presented in the modules served as a helpful review of information one may not have remembered since graduating from anesthesia school. Overall, the results showed an increase in every category, with a significant difference in willingness to increase the dose of succinylcholine. The implication is to share this knowledge with other anesthesia providers to elicit a practice change and help decrease succinylcholine-induced myalgia among surgical patients. Limitations of the research project include small sample size, sample bias, data collection process, timing, and setting. 15 CRNAs were invited to the Canvas module, and five completed the EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 19 learning exercise. A greater sample size would have been more reflective of accurate data. The study also had a sample bias since only CRNAs were included in the study. A way to have eliminated this is by having anesthesiologists and anesthesiologist's assistants included in the research project. The data collection process required volunteers to create accounts with Canvas to access the module. Many of the volunteers felt the onboarding difficult, which could explain the small sample size. In addition to the technological difficulties, the one-month time frame may have limited the number of participants. Perhaps more participants would have joined regardless of the complex onboarding process if the time frame had been extended. Lastly, all CRNAs who participated in the study worked at the same hospital. Diversifying the setting would have been ideal. Recommendations for future research include analyzing a larger sample size for long periods, diversifying the setting and anesthesia providers, and easier access to the module. Conclusion Succinylcholine-induced myalgia pain is an wanted and unacceptable side effect in modern practice. Surgical patients have added stress due to the surgical procedure being performed, and overall hospital stay and decreasing myalgia from their problem list is a measure anesthesia providers can play an active role in. Myalgia pain affects each patient differently and can lead to undesired consequences. For example, it delays postoperative rehabilitation, leads to depression, and increases medical costs. Research by Wong and Chung (2000) demonstrated that by using a higher dose, 1.5mg/kg, of succinylcholine, the contraction of muscle fibers would occur in synchrony, reducing muscle spindles' damage, thereby reducing overall myalgia pain. Because this is a modifiable practice change anesthesia providers can partake in, the goal is to educate other anesthesia providers to use the higher dose of succinylcholine to increase positive outcomes among surgical patients. This DNP project helped educate CRNAs on the importance of decreasing succinylcholine-induced myalgia and assessed the willingness to elicit a practice change. The data EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 20 analysis indicated a significant increase after the learning exercise. The goal is that this education is shared with other anesthesia providers to change their practice as well. EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 21 References Allen, T. K., Habib, A. S., Dear, G. L., White, W., Lubarsky, D. A., & Gan, T. J. (2007). How much are patients willing to pay to avoid postoperative muscle pain associated with succinylcholine? Journal of Clinical Anesthesia, 19(8), 601- 608. https://doi.org/10.1016/j.jclinane.2007.07.005 Dexter, F., Gan, T. J., Naguib, M., & Lubaraky, D. A. (2001). Cost identification analysis for succinylcholine. Anesthesia and Analgesia, 92(3), 693- 699. https://doi.org/10.1097/00000539-200103000-00028 Findlay, G. P., & Spittal, M. J. (1996). Rocuronium pretreatment reduces suxamethonium-induced myalgia: Comparison with vecuronium. British Journal of Anesthesia, 76(4), 526-529. https://doi.org/10.1093/bja/76.4.526 Gan, T.J. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research, 10, 22872298. https://doi.org/10.2147/JPR.S144066 Jain, P., Bhosale, U. A., & Soundattikar, G. (2019). A randomized controlled trial to compare preemptive analgesic efficacy and safety of pregabalin and gabapentin for succinylcholineinduced myalgia. Nigerian Medical Journal, 60(1), 27-32. https://doi.org/10.4103/nmj.NMJ_9_19 Lupien, A. E., Schoneboom, B. A., Wren, K. R. (2000). Limitations to self-care in the ambulatory surgical patient. Journal of Perianesthesia Nursing, 15(2), 102- 107. https://doi.org/10.1053/pa.2000.5784 Macario, A., Weigner, M., Truong, P., & Lee, M. (1999). Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesthesia and Analgesia, 88(5), 1085- 1091. https://10.1097/00000539199905000-00023 EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 22 McLoughlin, C., Leslie, K., & Caldwell, J. E. (1994). Influence of dose on suxamethoniuminduced muscle damage. British Journal of Anesthesia, 73(2), 194-198. https://doiorg.forward.marian.edu/10.1093/bja/73.2.194 Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer. Mikat-Stevens, M., Sukhani, R., Pappas, A. L., Fluder, E., Kelinman, B., Stevens, R. A. (2000). Is succinylcholine after pretreatment with d-tubocurarine and Lidocaine contraindicated for outpatient anesthesia? Anesthesia and Analgesia, 91(2), 312- 316. https://doi.org/10.1097/00000539-200008000-00015 Nagelhout, J.J, & Elisha, S. (2018). Nurse Anesthesia (6th ed.) Elsevier. Nasseri, K., & Arvien, S. (2016). Effects of low-dose ketamine on succinylcholine-induced postoperative myalgia in outpatient surgeries: A randomized, double-blind study. Journal of Pain Research, 9, 503- 508. https://doi.org/10.2147/JPR.S106576 Nimmo, S. M., McCann, N., Broome, I. J., & Robb, H. M. (1995). Effectiveness and sequelae of very low-dose suxamethonium for nasal intubation. British Journal of Anesthesia, 74(1), 31-33. https://doi.org/10.1093/bja/74.1.31 Nursing Theory. (2020). Lewins change theory. https://nursing-theory.org/theories-andmodels/lewin-change-theory.php Oxorn, D. C., Whatley, G. S., Knox, J. W., Hooper, J. (1992). British Journal of Anesthesia, 69(2), 200- 201. https://doi.org/10.1093/bja/69.2.200 Schreiber, J. U., Lysakowski, C., Fuchs-Buder, T., Tramer, M. R., Phil, D. (2005). Prevention of succinylcholine-induced fasciculation and myalgia. Anesthesiology, 103(4), 877-884. https://doi.org/10.1097/00000542-200510000-00027 Schreiber, J. U., Mencke, T., Biedler, A., Furst, O., Kleinschmidt, S., Buchinger, H., & FuchsBuder, T. (2003). Postoperative myalgia after succinylcholine: No evidence for an EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 23 inflammatory origin. Anesthesia & Analgesia, 96(6), 1640- 1644. https://doi: 10.1213/01.ANE.0000061220.70623.70 Shafy, S. Z., Hakim, M., Krishna, S. G., & Tobias, J. D. (2018). Succinylcholine-induced postoperative myalgia: Etiology and prevention. Journal of Medical Case Reports, 9(8), 264-266. https://doi.org/10.14740/jmc3107w Southern Pain and Neurological. (2020). What is myalgia: Causes, symptoms, and treatments. https://southernpainclinic.com/blog/what-is-myalgia-causes-symptoms-and-treatments/ Stewart, K. G., Hopkins, P. M., & Dean, S. G. (1991). Comparison of high and low doses of suxamethonium. Anesthesia, 46, 833-836. https://doi.org/10.1111/j.13652044.1991.tb09595.x Waters, D. J., & Mapleson, W. W. (1971). Suxamethonium pains: Hypothesis and observation. Anesthesia, 26(2), 127-14. https://doi.org/10.1111/j.1365-2044.1971.tb04753.x Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin's theory with leans system approach for change. The Online Journal of Issues in Nursing, 21(2), 1. https://:doi:10.3912/OJIN.Vol21No02Man04 Wong, S. F., & Chung, F. (2000). Succinylcholine-associated postoperative myalgia. Anesthesia, 55(2), 144-152. https://doi.org/10.1046/j.1365-2044.2000.055002144.x EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 24 Appendix A Theoretical Framework: Change Theory Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin's theory with leans system approach for change. The Online Journal of Issues in Nursing, 21(2), 1. https://:doi:10.3912/OJIN.Vol21No02Man04 EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 25 Appendix B Survey 1.) What is your age? o ____ 2.) How many years of experience do you have? o 1-5 years o 5-10 years o 10-15 years o 15-20 years o >20 years 3.) What type of setting do you work in? o Ambulatory outpatient o Inpatient o Mixed 4.) What is your level of education? o Certificate o Masters o Doctorate 5.) Gender? o Male o Female 6.) What dose of succinylcholine do you usually give? o .5mg/kg o 1mg/kg o 1.25mg/kg o 1.5mg/kg o Over 1.5mg/kg 7.) On a scale of 1-5, how willing are you to increase succinylcholine dosing to 1.5mg/kg? o o o o o Extremely unwilling Somewhat unwilling Neither willing or unwilling Somewhat willing Extremely willing EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 26 8.) On a scale of 1-5, how strongly do you agree with the following statements: 9.) On a scale of 1-5, please rate your confidence level with your knowledge in the following areas: EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 27 Appendix C IRB Approval EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 28 Appendix D Consent You are invited to participate in an investigative study titled The Effects of Educational Training of Succinylcholine Dosing on Myalgia Pain. This study is being conducted by Tiffany Cabeca, a doctoral student in the Nurse Anesthesia track at Marian University. You were selected to participate in this study because you are a CRNA who routinely uses succinylcholine. The purpose of this project is to educate CRNAs on the benefit of using higher dose succinylcholine to lessen succinylcholine-induced myalgia pain. If you agree to take part in this study, please complete the survey on the next page. This survey will ask about demographics, and your current knowledge on succinylcholine and myalgia pain. It will take you approximately 3 minutes to complete. Your answers in this study will remain confidential and results will be reported in the aggregate. Any risks to breach of confidentiality will be minimized by storage of all data in a password-protected computer kept in the home of the primary investigator and the deletion of all data upon completion of the study. Your participation in this study is completely voluntary and you can withdraw at any time. You are free to skip any question you choose. If you have questions about this study or if you have a study-related problem, you may contact the primary investigator, Tiffany Cabeca at (718) 791-3016. If you have any questions concerning your rights as a study subject, you may contact the Marian University Institutional Review Board Chair, Dr. Amanda C. Egan at aegan@marian.edu or irb@marian.edu. By completing the pre-survey, you are indicating that you are at least 18 years old, have read and understood this consent form, and agree to participate in this study. EDUCATIONAL TRAINING ON SUCCINYLCHOLINE 29  ...

... 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2022 Differences in Dosing of Dexamethasone and the Effect on Post-Operative Emesis in Healthy Surgical Patients Austin Miller Marian University Leighton School of Nursing Chair: Dr. Lee Summerlin-Grady _________________________________ Project Team Members: Beth Townsend, EdD, RN, EBP-C __________________________________ Jim Bartu, MSN, CRNA _________________________________ Date of Submission: December 6, 2021 2 Abstract Background and Review of Literature: Post-operative nausea and vomiting remains a constant threat to patients undergoing anesthesia. As such a myriad of drug compounds are utilized in the practice of anesthesia to prevent and thwart the unpleasant experience of post-operative nausea and vomiting. Although there has been agreement on the drug compounds that can successfully prevent such outcomes, little consensus has been developed for certain compounds, specifically dexamethasone. Purpose: To determine differences in efficacy in the prevention of post-operative emesis based on dosing of dexamethasone. Methods: A retrospective chart review was conducted on 10 healthy patients receiving > 0.1mg/kg of dexamethasone and 10 healthy patients receiving < 0.1mg/kg of dexamethasone at the induction of anesthesia. An evaluation of emesis in the post-operative period was evaluated. Microsoft Excel and Stat Crunch were used to analyze the data. Conclusion: A comparison of the group receiving <0.1 mg/kg and > 0.1 mg/kg of dexamethasone yielded no statistical difference in the ability to prevent postoperative emesis between the two groups. Keywords: Dexamethasone, Post-operative nausea and vomiting 3 Table of Contents Abstract...........................................................................................................................................2 Introduction .................................................................................................................................4 Background.....................................................................................................................4 Problem Statement......................................................................................................7 Organizational Gap Analysis of Project Site.................................................................8 Review of the Literature...........................................................................................................8 Theoretical Framework.....13 Goals/Objectives/Expected Outcomes .............................................................................16 Project Design Methods ............................................................................................................................16 Project Site and Population.......................................................................................17 Measurement Instrument(s) ...................................................................................18 Data Collection Procedure ........................................................................................19 Ethical Considerations/Protection of Human Subjects ................................19 Data Analysis and Results.........................................................................................................20 Conclusion .......................................................................................................................................21 References........................................................................................................................................23 Appendix I..............................27 Appendix II........................................................................................................................28 Appendix III.......................................................................................................................29 4 Differences in Dosing of Dexamethasone and the Effect on Post-Operative Emesis in Healthy Surgical Patients Introduction Post-operative nausea and vomiting is one of the most frequently encountered problems by surgical patients in the first 24 hours following surgery (Tateosian, 2018). It presents a risk for the patient in a multitude of physiologic manifestations, in addition to the discomfort it causes the patient. A number of strategies are utilized by anesthesia providers to effectively mitigate the untoward effects of post-operative nausea and vomiting. Chief among these strategies is pharmacological intervention, specifically the administration of dexamethasone, a corticosteroid. Although the effectiveness in preventing post-operative nausea and vomiting is well documented, there is a lack of consensus as to the most effective dose. Much contradictory information exists regarding the most appropriate dosage to provide the maximal effectiveness of the steroid. The purpose of this paper is to provide more data on the subject and help more fully establish a consensus on effective dosing in surgical patients. Background The primary purpose of anesthesia is to provide adequate levels of amnesia, analgesia, surgical anesthesia, and muscle relaxation. The techniques and spectrum of drugs used to achieve such desired levels present certain unfavorable effects for patients undergoing surgery (Nagelhout & Elisha, 2018). One such effect is the development of postoperative nausea and vomiting. Postoperative nausea and 5 vomiting (PONV) refers to nausea and vomiting occurring within the first 24 hours following surgery. It is one of the most commonly seen adverse effects in the post anesthesia care unit (PACU) (Tateosian, 2018). Estimates suggest that up to 30% of all surgical patients experience PONV (Collaborators & West Midlands Research, 2017). Studies indicate that patients with certain risk factors experience a PONV incidence rate of 80%. PONV usually subsides over time without intervention, but the detrimental effects it presents in the immediacy of post-operation cannot be overstated. Patients experiencing PONV are at risk for intravascular depletion, electrolyte imbalances, wound dehiscence, and respiratory compromise (Tateosian, 2018). Additionally, it presents a negative experience for patients undergoing surgery. Patients have rated PONV as a more negative outcome than the postoperative pain associated with surgery (Tateosian, 2018). The risk of PONV increases with certain patient populations, surgical influences, and other anesthetic factors. PONV incidence increases with patients of female gender, a previous history of motion sickness or PONV, those who are nonsmoking, and patients less than 50 years of age. The Apfel score utilizes these factors to determine patients risk of PONV when undergoing anesthesia for surgery. Presence of zero, one, two, three, or four risk factors represent a risk of PONV of 10, 20, 40, 60, or 80% respectively (Tateosian, 2018). Specific surgeries, such as cholecystectomies, laparoscopic procedures, and gynecological surgeries, increase the risk of PONV as well (Tateosian, 2018). Anesthetic factors play an additional role in the development of PONV. The length of anesthetic, use of opioids in a dose- 6 dependent manner, and administration of volatile anesthetics also increase the incidence of PONV (Tateosian, 2018). Given the detrimental effects of PONV on patients, anesthesia providers implement strategies to suppress some of these risk factors. The use of regional anesthesia decreases the need for both opioids and volatile anesthetics. Additionally, the use of total intravenous anesthetic can dramatically decrease the need for agents at significant risk for the development of PONV (Tateosian, 2018). Many pharmacological interventions are utilized as well in the form of anti-emetics. They include serotonin receptor antagonists, anticholinergics, and corticosteroids among others (Wang et al., 2000). One of the most frequently used corticosteroids is dexamethasone. It is generally used prophylactically at induction of anesthesia. Given the overwhelming glucocorticoid action of dexamethasone, it helps to prevent post-operative pain and opioid consumption. It also utilizes direct action to provide an anti-emetic effect for the patient (Tateosian, 2018). Dexamethasone also presents some untoward effects, despite its usefulness as an anti-emetic. Glucocorticoids are well established as having the ability to decrease wound healing, increasing wound infection, and increasing serum glucose (Tateosian, 2018). Single doses of dexamethasone have not shown any propensity to decrease wound healing or increase wound infection, although they have shown increases in serum glucose 6-12 hours following administration (Collaborators & West Midlands Research, 2017). As such, they are relatively contraindicated in patients with impaired serum glucose tolerance, such as those with diabetes mellitus. 7 Although the overwhelming support for the use of dexamethasone, as a prophylactic tool against PONV, is apparent, there is little consensus as to which dosage is the most effective at providing its desired anti-emetic effect. Many studies have provided contradictory information regarding the dosing of dexamethasone. One study conducted on women undergoing thyroidectomy, suggested that a dose of 5 mg was just as effective as a dose of 10 mg in preventing PONV (Wang et al., 2000). Another study conducted a meta-analysis on randomized control studies and found similar results indicating that a dose of 4-5 mg of dexamethasone was as effective as a dose of 8-10 mg in the reduction of PONV (De Oliveria et al., 2013). On the other hand, alternative studies have indicated higher doses of dexamethasone are more effective at preventing PONV. One such study found 8 mg of dexamethasone as the most effective dose to prevent PONV and the need for other anti-emetics in the 72 hours following surgery (Collaborators & West Midlands Research, 2017). Other studies have found that higher doses of dexamethasone lead to more opioid-sparing effect. They also indicate that higher doses decreased the variability of effectiveness within patients (De Oliveria, 2011). The lack of consensus indicates a need for further evaluation to determine the most effective dose in providing the most benefit to surgical patients. Problem Statement Post-operative nausea and vomiting is one of the most frequently encountered issues among surgical patients receiving anesthesia (Tateosian, 2018). Dexamethasone is a commonly used anti-emetic that has been shown to be effective in preventing PONV. There is a lack of consensus on the most effective dosage in 8 providing the maximal benefit to surgical patients. As such, does the administration of 8 mg of dexamethasone as compared to 4 mg at the induction of anesthesia, lead to fewer incidents of post-operative emesis in healthy surgical patients? To address the question at hand, the quality improvement approach will be in the form of chart review of surgical patients. Providing more data on the subject will hopefully lead to a more established consensus on appropriate dosing for the benefit of surgical patients in the future. Gap Analysis With an overall lack of consensus on appropriate dosing of dexamethasone at clinical sites, providing concrete evidence as to the minimum effective dosing would be beneficial in a multitude of ways. One would be an ability to provide a protocol for providers to follow and eliminate uncertainty. Another benefit would be potential cost savings. By identifying an effective dose for surgical patients, it could allow for more specific ordering and even decrease orders for dexamethasone. Finally, by providing evidence for an effective dose, it could alleviate PONV and lead to more efficient turnover in the PACU, saving money and providing a better experience for patients. Literature Review Search Methodology To find articles relating to the problem statement, a number of databases were used. The databases most useful in finding articles of interest were PubMed and Google Scholar. The articles used in the review of literature were mostly accessed through PubMed. Some articles were identified on Google Scholar but 9 were hidden behind a purchase requirement. In such instances, the articles were searched on PubMed and were made available by Marian University. The terms utilized in the search included dexamethasone, PONV, dosing, minimum effective dose, 4mg, and 8mg. Boolean phrases were also employed. In general, dexamethasone was combined individually with PONV, dosing, minimum effective dose, 4mg, and 8mg, using AND. In addition, dexamethasone was combined with 4mg and 8mg using AND between each term. The search terms resulted in 8,673 articles. Inclusion and exclusion criteria were used to hone the search into more appropriate terms. One criterion that was used was the year the article was published. Articles that pre-dated 2015 were not used in the review of literature; therefore, articles from 2014 and before were excluded from the review with a few exceptions. Studies conducted by De Oliveria et al. (2011), De Oliveria et al. (2013), and Wang et al. (2000) were included due to their impact on the subject of dexamethasone and PONV. They were pivotal articles that are still cited to this day. Additionally, only articles that were published in peer-reviewed journals were included in the review. The specialized nature of the subject led to a plethora of reviewed articles. Articles relating to the use of dexamethasone in pediatric surgical cases were excluded as this paper is focused on its impact on adults. Studies evaluating combinations of dexamethasone with other antiemetic drugs in which the dose of dexamethasone was identical in both study groups were also excluded due to an inability to extract any useful data regarding dexamethasone and its individual ability to prevent PONV. Additionally, articles evaluating effects that did 10 not include PONV were not utilized, as they did not comment on the emphasis of this paper. Finally, articles citing administration of dexamethasone in forms other than intravenous were omitted, as the focus of this paper is intravenous dosing. From the 8,673 articles searched, evaluated, and read, fourteen met criteria to be included in the review of literature. Consensus on the Use of Dexamethasone The use of dexamethasone as an anti-emetic and anti-inflammatory agent in the world of surgery has been well documented. However, upon thorough examination of the existing literature on the topic, little consensus exists as to the minimum dose needed to be effective to decrease incidence of PONV and minimize post-operative pain. In fact, much contradictory evidence exists in regards to effective dosing of dexamethasone. Evidence to Support Minimal Dosing Several studies have evaluated lower doses of dexamethasone and its effectiveness in comparison to efficacy of higher doses of the steroid. DeOliveria et al. (2013) evaluated doses of dexamethasone of 4-5 mg and doses of 8-10 mg. They performed a quantitative systematic review of nearly 90 studies relating to PONV and dosing with dexamethasone. Their review of nearly 7,000 surgical patients suggested similar efficacy between 4-5 mg and 8-10 mg of dexamethasone in the prevention of PONV. Wang et al. (2000) had similar findings in their dose-ranging study. The authors compared five different doses of dexamethasone administered to female patients undergoing thyroidectomy. Two doses were found to be effective at minimizing PONV, both the 5 mg and 10 mg doses. Interestingly enough, the 11 doses were found to be statistically similar in their prevention of PONV. A similar study conducted by Gupta et al. (2018), echoed similar sentiments to the previously mentioned studies. Gupta et al. (2018) evaluated dose impact of dexamethasone on PONV in patients undergoing laparoscopic cholecystectomy. Similarly they placed the subjects in their study into five different dosing groups. They found that the minimum dose of dexamethasone to prevent vomiting was 2 mg, while the minimum dose to prevent nausea was 4 mg. Firdaus et al. (2016) also evaluated the impact of dexamethasone on patients undergoing laparoscopic procedures. Their results were similar to Gupta et al. (2018) but they found that a hypnotic dose of propofol, 0.5 mg/kg, in conjunction with 4 mg of dexamethasone was equally as effective as 8 mg of dexamethasone in the prevention of PONV. Arumumgam et al. (2020) recently re-emphasized 4 mg of dexamethasone being an effective dose in the prevention of PONV in their study with patients undergoing knee and hip arthroplasty. The results of these studies suggest that doses of 4 mg of dexamethasone are sufficient in the inhibition of PONV in surgical patients. While providing adequate anti-emetic qualities, the detrimental effects of corticosteroids are reduced by providing the minimum effective dose. Argument for High-Dose Dexamethasone While a case has been made for 4 mg of dexamethasone being an effective anti-emetic, much research suggests higher efficacy for doses above 8 mg. A research study conducted by West Midlands Research (2017) in the United Kingdom evaluated the use of 8 mg of dexamethasone in patients undergoing bowel surgery. They found a significant reduction in the need for rescue anti-emetics and 12 incidences of postoperative vomiting. Yue et al. (2017) led a study with similar results in the evaluation of high-dose versus low-dose dexamethasone in patients electing for total knee or hip arthroplasty. High-dose dexamethasone was considered greater than 0.1 mg/kg and low dose was anything less than 0.1 mg/kg. The patients receiving high-dose dexamethasone had lower incidence of PONV than those receiving the low-dose. A study conducted by Sekhavat et al. (2015) also found 8 mg of dexamethasone to be an effective dose in the prevention of PONV in women undergoing abdominal hysterectomy. Both Cortes-Flores et al. (2018) and Tarantino et al. (2015) found 8 mg of dexamethasone to be the minimal effective dose in the prevention of PONV, in their studies regarding breast surgery and thyroidectomy, respectively. Finally, Yamanaga et al. (2017) evaluated dosedependent efficacy of dexamethasone in patients who underwent laparoscopic donor nephrectomy. A comparison was drawn between 4-6 mg and 8-14 mg of dexamethasone. Patients receiving doses of 8-14 mg were found to have decreased bouts of PONV in comparison to the group receiving lower doses. These studies directly contradict the previously mentioned studies indicating 4 mg of dexamethasone being a minimum effective dose in the prevention of PONV. Additional Benefits of High-dose Dexamethasone While higher doses of dexamethasone have been shown to be effective in the prevention of PONV, the higher doses have also been shown to be effective in other ways that may indirectly lead to lower levels of PONV. Both De Oliveria et al. (2011) and Mihara et al. (2016), conducted studies that indicated that doses of dexamethasone greater than 0.1 mg/kg lead to better pain control and minimized 13 consumption of opioids in the immediate postoperative period. These results were further endorsed by Yamanaga (2017), which indicated that doses of 8-14 mg of dexamethasone were not only effective in reducing PONV but decreased opioid consumption as well. Interestingly, Kleif et al. (2017) did not find 8 mg of dexamethasone to be an effective dose in the prevention of PONV in patients with suspected appendicitis undergoing laparoscopic procedures. However, they did find that dexamethasone did decrease pain, fatigue, and opioid consumption in the postoperative period. Cortes-Flores et al. (2018) found 8 mg of dexamethasone to be effective in the prevention of PONV as well as postoperative pain and analgesic requirements in their study with women undergoing breast surgery. Opioids are well known as emesis inducing agents. In fact, the Apfel scoring tool indicates dosing of opioids throughout a surgical case increases the chance of PONV by nearly 20%. Given the tremendous ability of higher doses of dexamethasone to decrease the need for opioids in the immediate postoperative period, it stands to reason that this indirectly reduces the incidence of PONV by extension as well. Theoretical Framework PONV is considered by surgical patients to be one of the most unpleasant symptoms experienced in the postoperative period. It is often cited as a worse symptom than the pain associated with the procedure (Tateosian et al., 2018). As such, the Theory of Unpleasant Symptoms, a middle range nursing theory, serves as a useful tool in the explanation of the question presented. The Theory of Unpleasant Symptoms is made up of three major concepts. They include symptoms, influencing factors, and performance outcomes (Lenz & Pugh, 2018). 14 Symptoms are the impetus for the theory and, as a result, are the central figure. Within the theory, symptoms are defined as experienced changes in normal functionality as perceived by patients. The theory asserts that symptoms can occur singularly or in succession of one another (Lenz & Pugh, 2018). As it relates to PONV seen in surgical patients, post-operative nausea may proceed vomiting, occur in conjunction with one another, or either may exist in isolation. Symptoms also manifest in varying facets. They include the severity, degree of distress, timing, and quality associated with the symptoms (Lenz & Pugh, 2018). In PONV the severity relates to the intensity of the symptom and may lead to vomiting, the degree of distress may exhibit differing levels of unpleasantness among patients, the timing is limited to the first 24 hours postoperatively, and the quality is specific to the experience of the patient. Three individual factors were identified as having influence on the symptoms experienced by patients in the theory. One such influencing factor named is the physiologic factor. This relates to the biologic makeup of the patient, the relationship to treatment undergone, and the genetic uniqueness of the patient (Lenz & Pugh, 2018). Another factor listed is the psychological factor. This refers to the mood of the patient prior to the experience of the symptoms and how their state of mind can determine their symptomology. Psychological factors can also impact how the patient responds to the symptoms and have an affect on the degree of distress experienced by the patient (Lenz & Pugh, 2018). The final factor is identified as the situational factor. This relates to the background of the patient, such as their socioeconomic status, access to healthcare, familial support. The 15 physical environment of the patient can also aid in the experience of symptoms, such as the altitude, temperature, or noise level of the surrounding setting (Lenz & Pugh, 2018). Performance outcomes are the final key concept within the Theory of Unpleasant Symptoms. This references the experience of symptoms by patients and their influence on the ability of the patient to function at a normal level. A patient experiencing symptoms may impact their ability to sleep, interact with others, or perform self-care or care for others (Lenz & Pugh, 2018). The three major concepts have a complex interplay among one another as evidenced by the graphic illustrated in Appendix II. The influencing factors have an impact on the symptoms experienced by the patient. The symptoms experienced by the patient have a tremendous influence on the patients ability to function at a normal level. The patients ability to function at a normal level affects their psychological factors, which can have a dramatic influence on physiologic factors. Alterations in some of the influencing factors and performance can affect the level of distress or quality of symptoms experienced by the patient (Lenz & Pugh, 2018). Quite clearly there is some level of influence or feedback of each concept on one another. The Theory of Unpleasant Symptoms provides a theoretical framework to direct the question presented. The aim of this paper is to determine differences in efficacy between 4 mg and 8 mg of dexamethasone in the prevention of postoperative vomiting in the first 24 hours following surgery. The dosage differences will have different physiologic impact on the patient. The differences in 16 physiologic response can lead to different experience of symptoms, notably postoperative vomiting in this situation. The presence or absence of postoperative vomiting will have a tremendous impact on the outcome for the patient in the form of enhanced recovery and return to baseline functionality. By examining the differences in physiologic response to the two doses of dexamethasone, it will be determined if one is more effective at preventing postoperative vomiting and enhancing patient recovery by the patient. Goals, Objectives, and Expected Outcomes The ultimate goal of this paper is to evaluate the differences, if any, in efficacy between <0.1 mg/kg and > 0.1 mg/kg of dexamethasone in the prevention of incidences of vomiting in surgical patients in the first 24 hours following procedure. Anesthesia providers will carry out the administration of the varying doses of dexamethasone, while registered nurses working in a post-anesthesia capacity will conduct the documentation of vomitus. The expected outcome should refine the consensus on effective dosing of dexamethasone in the operative period for surgical patients. Project Design The project is intended to be a quality improvement project in the form of an evaluation of practice intervention. Healthy surgical patients receiving either < 0.1 mg/kg or > 0.1 mg/kg of dexamethasone during the operative period will be evaluated as individual groups. The remainder of the administered anesthetic between the two groups should be as similar to one another as possible, in the form of dosing of general anesthesia compounds and drugs utilized in the maintenance of 17 anesthesia. Incidence of PONV and vomitus will be documented and recorded in the patients electronic health record. Utilizing the health record, a quantitative evaluation will be made regarding the different doses of dexamethasone and incidence of postoperative vomitus. Project Site and Population Project site was a full-service regional hospital in the Midwestern United States that offers full-time emergency services and a Level III trauma center. The hospital is full-service, offering full-time emergency services and a Level III trauma center. They offer a wide array of surgical procedures including general, gastrointestinal, orthopedic, gynecological, dental, and ear, nose, and throat surgeries. The facility employs numerous full-time anesthesiologists and three certified registered nurse anesthetists. One anesthesiologist oversees the anesthetics employed by two to three nurse anesthetists at staggered times. The hospital also has a two-phase post anesthesia care unit staffed by registered nurses. Phase 1 is set-aside for patients undergoing general anesthesia, while Phase 2 is reserved for patients undergoing monitored anesthesia care. The population being evaluated in this study was healthy surgical patients undergoing general anesthetics at St Francis Lafayette East. Included were adult patients over the age of 18 years undergoing surgical procedures and a designation of ASA 1 or ASA 2 from the administering anesthesiologist as documented in the health record. The patient will need to have undergone a general anesthetic in some form of a surgical procedure and received either < 0.1 mg/kg or > 0.1 mg/kg of dexamethasone within 15 minutes of the induction of anesthesia. Additional criteria 18 will include the reception of induction medications dosed within the following ranges: fentanyl (0.5-1 mcg/kg), lidocaine (0.5-1 mg/kg), propofol (1.5-2.5 mg/kg), hydromorphone (0.1 mg/kg), and rocuronium (0.6-1.2 mg/kg). Maintenance will be in the form of volatile anesthetic by means of Sevoflurane administration of 0.5-1.3 minimum alveolar concentration on 1-2 liters of fresh gas flow. The patient will also receive 4 mg of ondansetron. Exclusion criteria will include patients under the age of 18 years, patients with an ASA 3 or ASA 4 designation, patients receiving an anesthetic other than a general, patients that do not receive specified doses of dexamethasone, induction medications, maintenance medications, or ondansetron. Patients undergoing laparoscopic procedures will also be excluded as this surgical technique can amplify PONV. The study was conducted by utilizing a retrospective analysis of data in the form of chart review. Patients meeting inclusion criteria and having undergone surgical procedures within the last year will be selected at random. In the electronic health record review, the incidence of vomitus was evaluated in individuals receiving < 0.1 mg/kg of dexamethasone and > 0.1 mg/kg of dexamethasone. Once a sufficient population of both groups of individuals was established, a statistical analysis of the data was conducted to determine if there was a significant difference between the two groups and the prevention of emesis in the immediate postoperative period. Measurement Instruments 19 Incidence of vomitus by surgical patients was conducted by chart review and electronic evaluation in the post anesthesia care unit following the surgical procedure. The measurement of vomitus was a straightforward and strong method of evaluating the outcome of interest. However, the measurement was dependent on the documentation of the incident by the nursing staff in the postoperative period. Data Collection Anesthesia care providers conducted documentation of medications administered in the preoperative and intraoperative period of the procedure. Registered nurses working in a post anesthesia capacity conducted documentation of postoperative PONV, incidence of vomitus, and postoperative medications. This documentation should be conducted regardless of ongoing investigation, as it is required by hospital and state policy. The incidence of vomitus was tallied for each group using retrospective chart review and determined to be statistically significant or not by means of statistical analysis tools. The data was collected from a twoweek period from October 25, 2021 to November 5, 2021. Ethical Considerations/Protection of Human Subjects Both the Marian Internal Review Board and Franciscan Internal Review board approval were obtained prior to initiating the project. Additionally, all participants were protected by the Health Insurance Portability and Accountability Act of 1996, which ensures the health information of individuals, is kept private (Office for Civil Rights, 2020). The chart reviews of the patients included in the study were conducted by the DNP student and done in a hospital setting and posed 20 no more risk of breach than the day of their original surgical procedure. Any patient identifiers were removed and patients were anonymously placed into groups according to their dose of dexamethasone received. All access to patient records by the co-investigators is password protected. Data Analysis Data analysis was conducted using Stat Crunch software. The Chi-Square test was utilized to determine statistical significance between the two groups, with a statistical significance of P < 0.05. Results Participants Twenty subjects undergoing general anesthesia at Franciscan Lafayette East were chosen at random from this time period and placed into groups receiving < 0.1 mg/kg and > 0.1 mg/kg of dexamethasone, granted they met inclusion criteria. Ten individuals were found to meet criteria for each group. The group receiving < 0.1 mg/kg of dexamethasone included eight males and two females with an average age of 61.3 years. The group receiving > 0.1 mg/kg of dexamethasone included five males and five females with an average age of 58.9 years (see Appendix III). Post-Operative Emesis There was not a statistically significant difference in the dosing of dexamethasone and its resulting effect on postoperative emesis. The Chi Square test resulted in a P value of 0.555950672, indicating a lack of statistical difference between the two groups in this study. Discussion 21 The aim of this study was to determine whether a difference in dosing of dexamethasone led to differences in post-operative emesis in healthy patients undergoing general anesthesia. Two different groups were assessed in this study, one group receiving high-dose steroid or > 0.1 mg/kg of dexamethasone and one group receiving low-dose steroid or <0.1 mg/kg of dexamethasone. There was not a statistical difference in the two groups and their ability to prevent post-operative emesis. The results echoed studies conducted by DeOliveria (2013), Wang et al. (2000), Gupta et al. (2018), Arumumgam et al. (2020), and Firdaus et al. (2016), which all suggested that lower dosing of dexamethasone led to similar efficacy as higher doses in the prevention of post-operative nausea and vomiting. There were several limitations to this study given its retrospective nature. Much larger multi-site, randomized controlled studies would be needed to extract any meaningful data regarding dexamethasone and its minimum effective dose. There could certainly be provider bias with dosing of dexamethasone when evaluating the results from just one clinical site with this study. Additionally, there was significant emphasis placed on chart review in this study and a dependence on accurate documentation of events experienced by the patients. It is possible that some of these patients experienced vomiting that was not accurately recorded or occurred after the patient had left the PACU. Conclusion This study suggests that lower doses of dexamethasone present similar levels of efficacy in the prevention of postoperative nausea and vomiting. Given the level of importance of preventing post-operative nausea and vomiting to patients, studies 22 like this should help to identify the most efficacious dose of dexamethasone, while preventing some of the untoward effects seen with high doses of steroids (Tateosian, 2018). Further multi-site, randomized controlled studies will be needed to clarify the most appropriate dosing of dexamethasone in surgical patients. 23 References Arumugam, S., Woolley, K., Smith, R. A., Vellanky, S., Cremins, M. S., & Dulipsingh, L. (2020). Comparison of dexamethasone 4mg vs 8mg doses in total joint arthroplasty patients: A retrospective analysis. Cureus, 12(9): e10295. doi:10.7759/cureus.10295 Ascension Health. (2021, April 15). Ascension St. Vincent Anderson. https://healthcare.ascension.org/Locations/Indiana/INEVA/AndersonAscension-St-Vincent-Anderson Collaborators, D.T. and C. West Midlands Research. (2017). Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: Randomized controlled trial. British Medical Journal, 357, 1-10. https://dx.doi.org/10.1136/bmj.j1455 Cortes-Flores, A. O., Jimenez-Tornero, J., Morgan-Villela, G., Delgado-Gomez, M., Zuloaga-Fernandez, J., Garcia-Renteria, J., Rendon-Felix, J., Fuentes-Orozco, C., Amezcua, M., Ambriz-Gonzales, G., Alvarez-Villasenor, A. S., Urias-Valdez, D., Chavez-Tostado, M., Contreras-Hernandez, G. I., Gonzales-Ojeda, A. (2018). Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial. European Journal of Cancer Care, 27(1), e12686. https://doiorg.forward.marian.edu/10.1111/ecc.12686 24 De Oliveria, G. S., Almeida, M. D., Benzon, H. T., McCarthy, R. J. (2011). Perioperative single dose systemic dexamethasone for post-operative pain: A meta-analysis of randomized controlled trials. Anesthesiology, 115(3), 575-588. Doi: 10.1097/ALN.0b013e31822a24c2 De Oliveria, G. S., Castro-Alves, L. J., Ahmad, Shireen, Kendall, M., & McCarthy, R. J. (2013). Dexamethasone to prevent postoperative nausea and vomiting: An updated meta-analysis of randomized controlled trials. Anesthesia & Analgesia, 116(1), 58-74. Doi: 10.1213/ANE.0b013e31826f0a0a Firdaus, K., Adnan, D., Muhammad, M., Rahman, R. A., Kamaruzaman, E., Manap, N. A., Vera, S. R., & Zain, J. (2016). Dexamethasone 8 mg versus dexemethasone 4 mg with propofol 0.5 mg/kg for the prevention of postoperative nausea and vomiting after laparoscopic gynaecology procedure. International Medical Journal, 23(1), 43-46. Gupta, R., Srivastava, S., Dhiraaj, S., & Chovatiya, P. P. (2018). Minimum effective dose of dexamethasone in combination with midazolam as prophylaxis against postoperative nausea and vomiting after lapraroscopic cholecystectomy. Anesthesia Essays and Researches, 12(2), 396-401. Doi: 10.4103/aer.AER_19_18 Kleif, J., Kirkegaard, A., Vilandt, J., & Gogenur, I. (2017). Randomized clinical trial of preoperative dexamethsone on postoperative nausea and vomiting after laparoscopy for suspected appendicitis. British Journal of Surgery, 104(4), 384392. https://doi-org.forward.marian.edu/10.1002/bjs.10418 25 Lenz, E. R. & Pugh, L. C. (2018). Theory of unpleasant symptoms. In M. J. Smith, & P. R. Liehr (Eds.), Middle range theory for nursing (4th ed., pp. 179-214). Springer Publishing Company Mihara, T., Ishii, T., Ka, K., & Goto, T. (2016). Effects of setoids on quality of recovery and adverse events after general anesthesia: Meta-analysis and trial sequential analysis of randomized clinical trials. PLoS ONE, 11(9),1-14. Doi:10.1371/journal.pone.0162961 Nagelhout, J.J. & Elisha, S. (2018). Nurse anesthesia (6th ed.). Elsevier. Sekhavat, L., Davar, R., & Behdad, S. (2015). Efficacy of prophylactic dexamethasone in prevention of postoperative nausea and vomiting. Journal of Epidemiology and Global Health, 5(2), 175-179. https://doi.org/10.1016/j.jegh.2014.07.004 Tarantino, I., Warschkow, R., Beutner, U., Kolb, W., Luthi, A., Luthi, C., Schmied, B. M., Clerici, T. (2015). Efficacy of a single preoperative dexamethasone dose to prevent nausea and vomiting after throidectomy (the tPONV study): A randomized, double-blind, placebo-controlled clinical trial. Annals of Surgery, 262(6), 934-940. DOI: 10.1097/SLA.0000000000001112 Tateosian, V. S., Champagne, K., & Gan, T. J. (2018). What is new in the battle against postoperative nausea and vomiting? Best Practice & Research Clinical Anaesthesiology, 32(2), 137-148. https://doi.org/10.1016/j.bpa.2018.06.005 26 Office for Civil Rights. (2020, November). Health Information Privacy. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/forindividuals/guidance-materials-for-consumers/index.html Wang, J. J., Ho, S. T., Lee, S. C., Liu, Y. C., & Ho, C.M. (2000). The use of dexamethasone for preventing postoperative nausea and vomiting in females, undergoing thyroidectomy: A dose-ranging study. Anesthesia & Analgesia, 91(6), 1404-1407. Doi: 10.1097/00000539-200012000-00019 Yamanaga, S., Posselt, A. M., Freise, C. E., Kobayashi, T., Tavakol, M., & Kang, S. (2017). A single perioperative injection of dexamethasone decreases nausea, vomiting, and pain after laparoscopic donor nephrectomy. Journal of Transplantation, 2017, 1-8. https://doi.org/10.1155/2017/3518103 Yue, C., Wei, R., & Liu, Y. (2017). Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: A systematic review and meta-analysis of randomized trials. Journal of Orthopaedic Surgery and Research, 12(1), 100111. Doi: 10.1186/s13018-017-0601-4 27 Appendix I Literature Review Matrix Reference in APA format Collaborators, D.T. and C. West Midlands Research. (2017). Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: Randomized controlled trial. British Medical Journal, 357, 1-10. https://dx.doi.org/10.1136/bmj.j1455 De Oliveria, G. S., Almeida, M. D., Benzon, H. T., McCarthy, R. J. (2011). Perioperative single dose systemic dexamethasone for post-operative pain: A meta-analysis of randomized controlled trials. Anesthesiology, 115(3), 575-588. Doi: 10.1097/ALN.0b013e31822a24c2 De Oliveria, G. S., Castro-Alves, L. J., Ahmad, Shireen, Kendall, M., & McCarthy, R. J. (2013). Dexamethasone to prevent postoperative nausea and vomiting: An updated meta-analysis of randomized controlled trials. Anesthesia & Analgesia, 116(1), 58-74. Doi: 10.1213/ANE.0b013e31826f0a0a Level of Evidence Variables Sample Instruments Results Level 1 Vomiting within 24 hours of surgery, vomiting within 72-120 hours, fatigue and quality of life at 120 hours, time to return to fluid and food intake, length of hospital stay, and adverse events N=1350, 674 receiving dexamethasone in additon and 676 receiving standard of care undergoing elective open or laparocopic bowel surgery Reported incidents by either patient or clinician and timing of incidents Vomiting within 24 hours was seen in 172 (25.5%) receiving dexamethasone and 223 (33.0%) of participants receiving standard of care. Additional antiemetics were given to 39.3% of participants receiving dexamethasone and 51.9% receving standard of care. Level 1 Pain at 0-4 hr postoperatively, 24 hour postoperatively, and cumulative opioid consumption in postoperative period Visual analog or numeric rating scale pain scores and timing of pain Reduced postoperative pain and opioid consumption was seen in patients receiving doses of dexamethasone > 0.1 mg/kg Level 1 Incidence of PONV in first 24 hours following surgery N=2751, surgical patients receiving dexamethasone, broken into 3 dosage groups: low (less than 0.1 mg/kg), intermediate (0.11-0.2 mg/kg), and high (>=0.21 mg/kg) doses N=6696, surgical patients receiving 4-5 mg of dexamethasone and patients receiving 8-10 mg of dexamethasone Reported incidents of PONV Similar clinical effects are seen with doses 4-5 mg and 8-10 mg of dexamethasone in regards to the reduction of PONV Level 1 Incidence of nausea, vomiting, severity of nausea, the use of rescue anti-emetic, and postoperative pain N=155, surgical Visual analog scale to determine patients undergoing severity of vomiting and pain, laparoscopic record of vomiting incidents cholecystectomy, 31 participants were randomly assigned to one of five groups receiving various doses of dexamethasone (0 mg, 1 mg, 2 mg, 4 mg, and 8 mg) The minimum effective for prevention of nausea was 4 mg of dexamethasone and for prevention of vomiting was 2 mg Level 1 PONV evaluated by incidences of nausea and vomiting, episodes of vomiting, and use of rescue anti-emetics Evaluation by nurse anesthetists every 4 hours and patient complaint Dexamethasone doses of 5 mg and 10 mg provided equal effectiveness in preventing PONV in women undergoing thyroidectomy Level 1 Incidences of nausea, vomiting, and need for rescue anti-emetic in first 24 hours following surgery N=225 women undergoing thyroidectomy, 45 participants randomly assigned to one of five groups receiving various doses of dexamethasone (0 mg, 1.25 mg, 2.5 mg, 5 mg, and 10 mg) N=100, women undergoing total abdominal hysterectomy, with 50 receiving 8mg of dexamethasone and 50 receiving saline Patients report of nausea on a linear scale of 0-10 and record of patient vomiting or retching Dexamethasone dose of 8 mg was shown to be effective in reducing PONV in women undergoing abdominal hysterectomy Level 1 Incidences of PONV and pain the first 24 hours following surgery Patient report of nausea and vomiting and report of pain on a linear scale High-dose dexamethasone showed lower incidence of PONV and pain in the first 24 hours following surgery Level 1 Quality of Recovery following surgery, using 5 criteria which include physical comfort, emotional state, physical independence, psychological support, and pain Incidence of PONV and pain in the first 24 hours following laparoscopic donor nephrectomy N=774, surgical patients undergoing either total hip or knee arthroplasty, with individuals either receiving high-dose dexamethasone (>0.1mg/kg) or lowdose dexamethasone (<0.1mg/kg) N=301, patients undergoing general anesthesia QoR-40 questionnaire results Dexamethasone doses of 0.1 mg/kg lead to improved scores of physicial independence and pain control compared to those receving dexamethasone 0.05 mg/kg Gupta, R., Srivastava, S., Dhiraaj, S., & Chovatiya, P. P. (2018). Minimum effective dose of dexamethasone in combination with midazolam as prophylaxis against postoperative nausea and vomiting after lapraroscopic cholecystectomy. Anesthesia Essays adn Researches, 12(2), 396-401. Doi: 10.4103/aer.AER_19_18 Wang, J. J., Ho, S. T., Lee, S. C., Liu, Y. C., & Ho, C.M. (2000). The use of dexamethasone for preventing postoperative nausea and vomiting in females, undergoing thyroidectomy: A dose-ranging study. Anesthesia & Analgesia, 91 (6), 1404-1407. Doi: 10.1097/00000539-200012000-00019 Sekhavat, L., Davar, R., & Behdad, S. (2015). Efficacy of prophylactic dexamethasone in prevention of nausea and vomiting. Journal of Epidemiology and Global Health, 5(2), 175-179. https://doi.org/10.1016/j.jegh.2014.07 .004 Yue, C., Wei, R., & Liu, Y. (2017). Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: A systematic review and meta-analysis of randomized trials. Journal of Orthopaedic Surgery and Research, 12(1), 100-111. Doi: 10.1186/s13018-017-0601-4 Mihara, T., Ishii, R., Ka, K., & Goto, T. (2016). Effect of steroids on quality of recovery and adverse events after general anesthesia: Meta-analysis and trial sequential analysis of randomized clinical trials. PLoS ONE, 11(9), 1-14. Doi: 10.1371/journal.pone.0162961 Level 1 N=281, patients Use of opioids and rescue antiundergoing emetics laparoscopic donor nephrectomy, with 70 receiving 4-6 mg of dexamethasone, 100 receiving 8-14 mg of dexamethasone, and 111 receiving none at all Incidence of PONV, PACU N=715, patients Reported incidence of PONV time, and length of stay undergoing total hip or knee arthroplasty, with 148 receiving 4mg of dexamethasone and 567 receiving 8mg of dexamethasone Patients receiving 8-14 mg of dexamethasone had decreased and opioid consumption in comparison to the patients who received lower doses or who did not receive dexamethasone Level 1 Incidence of PONV The two groups were similar in their prevention of PONV in the surgical patients Level 1 Incidence of PONV, N=116, patients Postoperative questionnaire including pain, fatigue, undergoing surgery for sleep, opioid suspected appendicitis, consumption, use of with 57 receiving 8 mg antiemetics, quality of of dexamethasone and recovery and duration of 59 in the placebo convalesence group Level 1 Incidence of PONV at 4, 8, 16, 24, 32, and 48 hours after surgery N=70, patients undergoing thyroidectomy, 35 receiving saline and 35 receiving 8 mg of dexamethasone Assessment by nursing staff in the Patients receiving 8 mg of dexamethasone had half the postoperative period incidence of PONV as the control group Level 1 Incidence of PONV and pain at 1 hour before surgery and 1, 6, 12, and 24 hours after surgery N=80, women patients undergoing conservative surgery for breast cancer, with 40 receiving placebo via saline and 40 receiving 8 mg of dexamethasone Reported incidence of PONV, pain, and measurement of postoperative respiratory function utilizing spirometry Yamanaga, S., Posselt, A. M., Freiese, C. E., Kobayashi, T., Tavakol, M., & Kang, S. (2017). A single perioperative injection of dexamethasone decreases nausea, vomiting, and pain after laparoscopic donor nephrectomy. Journal of Transplantation, 2017, 1-8. https://doi.org/10.1155/2017/3518103 Arumugam, S., Woolley, K., Smith, R. A., Vellanky, S., Cremins, M. S., & Dulipsingh, L. (2020). Comparison of dexamethasone 4mg vs 8mg doses in total joint arthroplast patients: A retrospective analysis. Cureus, 12(9): e10295. doi:10.7759/cureus.10295 Firdaus, K., Adnan, D., Muhammad, M., Rahman, R. A., Kamaruzaman, E., Manap, N. A., Vera, S. R., & Zain, J. (2016). Dexamethasone 8 mg versus dexemethasone 4 mg with propofol 0.5 mg/kg for the prevention of postoperative nausea and vomiting after laparoscopic gynaecology procedure. International Medical Journal, 23(1), 43-46. Kleif, J., Kirkegaard, A., Vilandt, J., & Gogenur, I. (2017). Randomized clinical trial of preoperative dexamethsone on postoperative nausea and vomiting after laparoscopy for suspected appendicitis. British Journal of Surgery, 104(4), 384-392. https://doiorg.forward.marian.edu/10.1002/bjs.1 0418 Tarantino, I., Warschkow, R., Beutner, U., Kolb, W., Luthi, A., Luthi, C., Schmied, B. M., Clerici, T. (2015). Efficacy of a single preoperative dexamethasone dose to prevent nausea and vomiting after throidectomy (the tPONV study): A randomized, double-blind, placebocontrolled clinical trial. Annals of Surgery, 262(6), 934-940. DOI: 10.1097/SLA.0000000000001112 Cortes-Flores, A. O., Jimenez-Tornero, J., Morgan-Villela, G., Delgado-Gomez, M., Zuloaga-Fernandez, J., GarciaRenteria, J., Rendon-Felix, J., FuentesOrozco, C., Amezcua, M., AmbrizGonzales, G., Alvarez-Villasenor, A. S., Urias-Valdez, D., Chavez-Tostado, M., Contreras-Hernandez, G. I., GonzalesOjeda, A. (2018). Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial. European Journal of Cancer Care, 27(1), e12686. https://doiorg.forward.marian.edu/10.1111/ecc.1 2686 Level 1 N=100, women undergoing laparoscopic gynaecology surgery, 50 receiving 8 mg of dexamethasone, 50 receiving 4 mg of dexamethasone and 0.5 mg/kg of propofol Reported incidence of PONV and use of rescue anti-emetics Dexamethasone doses of 4mg and 8mg were equally effective in preventing PONV Patients receiving 8 mg of dexamethasone did see reduced incidence of PONV but can reduce pain, fatigue, and opioid consumption 8 mg of dexamethasone lead to significant lower incidences of PONV, pain, and improved respiratory parameters, and reduced need for additional postoperative analgesic and antiemetic drugs 28 Appendix II Note. From Theory of Unpleasant Symptoms [Picture] by Lenz & Pugh, 2018, Middle Range Theory of Nursing 29 Appendix III Procedure ORIF Forearm ORIF Hip ORIF Humerus Lumbar Fusion Diskectomy ORIF Wrist Shoulder Arthoscopy Shoulder Arthoscopy Shoulder Arthoscopy Total Hip Replacement Excision Inguinal Lymph Node Lumbar Fusion Diskectomy Knee Replacement Shoulder Arthroscopy Right Thyroid Lobectomy Left Thyroidectomy Endoscopic Antrostomy Rectal Exam Diskectomy ASA Age Sex 1 24 M 2 90 M 2 78 F 2 78 F 2 57 M 2 57 M 2 56 M 2 36 M 2 55 M 2 66 F 2 2 2 2 2 56 70 40 71 85 M F M F F 2 2 62 41 M M 2 2 2 79 41 60 M M F <.1mg/kg x x x Emesis in Post-Op? N N N N N N N N N x N x x x N N N N N >.1 mg/kg x x x x x x x x x N N x x x x Chi Square Result P = 0.55950672 N N N  ...

... THE EFFECT OF ONLINE PEER MENTOR TRAINING 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2022 The Effect of Formal Online Peer Mentor Training on Mentor Self-Confidence Angelica Hughes Marian University Leighton School of Nursing Chair: Dr. Lee Summerlin-Grady X Dr. Lee Summerlin-Grady First Reader: Dr. Beth Townsend X Dr. Beth Townsend Date of Submission: THE EFFECT OF ONLINE PEER MENTOR TRAINING 2 Table of Contents Abstract.......................................................................................................................................... 4 Introduction .................................................................................................................................... 5 Background......................................................................................................................... 5 Problem Statement ............................................................................................................. 7 Organizational Gap Analysis of Project Site .................................................................. 7 Review of the Literature ................................................................................................................. 8 Literature Themes ....................................................................................................9 Peer Support ............................................................................................................9 Training and Mentor Confidence...........................................................................10 Formal Training.....................................................................................................11 Training Format.....................................................................................................11 Other Training Themes..........................................................................................12 Theoretical Framework Model.. 13 Matched Dyads...................................................................................................................14 Goals and Purpose..............................................................................................................14 Solidifying the Relationship...............................................................................................15 Advocacy and Guidance.....................................................................................................15 Culture Integration.............................................................................................................15 Resource Mobilization.......................................................................................................16 Objectives.......................................................................................... 16 Project Design ...16 Project Site and Population ............................................................................................... 17 THE EFFECT OF ONLINE PEER MENTOR TRAINING 3 Methods .....17 Measurement Instrument(s) .............................................................................................. 18 Data Collection Procedure ................................................................................................ 19 Ethical Considerations/Protection of Human Subjects ......19 Timeline 19 Data Analysis and Results..20 Demographics20 Descriptive Statistics 20 Inferential Statistics .21 Discussion......................................................................................................................................22 Conclusion .................................................................................................................................... 23 References......................................................................................................................................25 Appendices.........30 Appendix A ...................................................................................................................... 30 Appendix B....................................................................................................................... 31 Appendix C....................................................................................................................... 33 Appendix D....................................................................................................................... 35 Appendix E....................................................................................................................... 36 Appendix F....................................................................................................................... 38 Appendix G....................................................................................................................... 39 THE EFFECT OF ONLINE PEER MENTOR TRAINING 4 Abstract The stress levels experienced by student registered nurse anesthetists (SRNAs) make them excellent candidates to experience the benefits of peer mentoring. Many students assigned as mentors lack the necessary skills to support an adequate mentoring relationship. Mentor training programs have proven successful in providing mentors with the skills, knowledge, and selfconfidence to support the next generation of SRNAs. The purpose of this quality improvement project was to determine if DNP nurse anesthesia peer mentors, who have undergone formal online mentor training, experience higher levels of confidence after participating in formal mentor training. Thirty-eight students from two cohorts of the nurse anesthesia program were invited to enroll in the online Mentor Training Workshop via Canvas. The mentor training workshop featured education about mentorship best practices for developing a successful mentoring relationship. Participants began by assessing their pre-workshop confidence level through an adapted version of the Mentor Competency Assessment survey. Participants were granted self-guided access to the workshop modules with a deadline of three weeks. The workshop entitled SRNA Mentor Training consisted of four education modules based on objectives criterion. Participants then completed the same survey after completion of the workshop. Participants responses indicated improved overall confidence with mentoring and in their ability to meet the needs of their mentees. These results were found to be statistically significant with a value of 0.018 and 0.009, respectively (P< 0.05). Keywords: SRNA mentors, effective mentors, peer mentor training, student mentor training, mentor self-confidence, formal mentor training, online peer mentor training, Mentor Competency Assessment, graduate nursing mentor THE EFFECT OF ONLINE PEER MENTOR TRAINING 5 The Effect of Formal Online Peer Mentor Training on Mentor Self-Confidence This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. The existing peer mentor program supports Doctor of Nursing Practice (DNP) essential VIII which requires advanced practice nurses to guide, mentor, and support other nurses to achieve excellence in nursing practice (Marian University, 2019, p. 84). However, the skills of mentoring are not inherently possessed by all graduate students. Development and adoption of a formal peer mentor training program within the nurse anesthesia track could provide student mentors with the knowledge, tools, and resources necessary to build better mentoring relationships and improve mentors confidence level with mentoring. Background According to Chipas et al. (2012), most student registered nurse anesthetists (SRNAs) report stress levels that they believe negatively affect their general well-being. These stress levels are related to academic and clinical performance, financial burdens, adapting to preceptor teaching styles, and information overload. SRNAs have listed peer support as a top suggestion for improvement in anesthesia programs to increase well-being (Chipas et al., 2012). Peer mentoring has been shown to reduce student stress and anxiety and improve student engagement and satisfaction (Andre et al., 2017; Sprengal & Job, 2004). Several studies consider mentor training to be best practice for the development of a successful mentoring relationship (Fornari et al., 2014; Kibbe et al., 2016, Nick et al., 2012; Straus et al., 2013) and improved mentor confidence (Feldman et al., 2012; Kibbe et al., 2016; Lau et al., 2016; Nick et al., 2012; Osman & Gottlieb, 2018; Pfund et al., 2015; Sheri et al., 2019; Spiva et al., 2017; Tsen et al., 2012; Tuomikoski et al., 2020; Yau et al., 2020). THE EFFECT OF ONLINE PEER MENTOR TRAINING 6 Mentoring allows for the development of a relationship where the mentor advises based on personal experience. A mentor is a person who supports, advises, and guides another individual, usually regarding a career path. Mentoring can provide mentees with resources, education, emotional support, social inclusion, and networking (Sprengel & Job, 2004). Mentors are a relatable resource that can provide the mentee with information about norms, values, beliefs, assumptions, and myths in a profession (Grossman, 2012). Nurses who seek a graduate degree in anesthesia can benefit from this type of relationship with a more experienced student. However, each peer mentor brings their own unique skills and experience to the relationship which may not include mentor training. Even naturally skilled mentors can benefit and improve mentor skills by training and studying the qualities of successful mentorships (Straus et al. 2013). The mentorship relationships can be formal or informal depending on personal preferences and the presence of institutional programs. Informal, also known as unstructured, mentoring programs have been associated with poor mentoring relationships due to lack of tools for developing the mentor-mentee relationship (Fornari et al., 2014). This is particularly important among minorities, especially if the campus is primarily a single culture. Structured programs have the potential to provide culturally aware mentors that are more equipped to work with minority students (Grossman, 2012). Mentor training could assist mentors with developing cultural competence and provide the tools necessary for maintaining a structured mentor-mentee relationship (Sheri, 2019). Straus et al. (2013) utilized qualitative research to explore the reasons for failed mentoring relationships which include poor communication skills, lack of commitment, and lack of mentor experience. Mentor training can equip mentors with the skills and resources needed to mitigate these challenges (Sheri, 2019). According to Pallaria et al. (2019), those that utilized THE EFFECT OF ONLINE PEER MENTOR TRAINING 7 structured mentor training experienced increased mentor knowledge. Long-term benefits of mentor training were increased effectiveness and academic productivity, improved mentoring skills, enthusiasm and confidence, and increased occurrence of promotions, awards, and grants (Sheri, 2019). Problem Statement Mentorship provides an opportunity to reduce student stress by providing an empathetic resource who is experienced with the academic and clinical environment. However, students assigned as mentors may lack the knowledge, skills, and attitudes to be an effective, confident peer mentor. Providing mentors with formal training could help guide the relationship, improve mentor confidence, and create more meaningful relationships between mentors and mentees. Peer mentoring provides benefits to both the mentor and the mentee. The purpose of this quality improvement project is to determine if DNP nurse anesthesia peer mentors, who have undergone formal online mentor training, experience higher levels of confidence after participating mentor training. Organizational Gap Analysis of Project Site A peer mentor program for student registered nurse anesthetists (SRNAs) exists at a small midwestern university; however, it lacked the structure and resources needed to develop and support the mentor-mentee relationship. There was an opportunity to improve the mentor program to achieve excellence within this graduate requirement. A formal, structured mentor training program improves mentors confidence with diversity, mentoring relationships, communication, and knowledge of how to address difficult circumstances and conversations (Sheri et al., 2019). Developing these mentoring skills will increase the number of quality nursing mentors within the university and the workforce. THE EFFECT OF ONLINE PEER MENTOR TRAINING 8 Review of Literature The goal of the literature review was to explore the characteristics of successful mentors and mentorship programs. Specifically, the focus was on the use of formal peer mentor training to improve the mentors self-confidence with being a mentor and providing support to the mentee. The search also highlighted some common themes and evidence-based features of mentoring programs and mentor training. Keywords and phrases searched for this review include mentor training, mentor education, mentor competency, mentor characteristics, peer mentoring, mentor knowledge, mentor development, formal mentor program, formal mentor training program, and structured mentor program. Boolean searches include mentor training and confidence; mentor education and confidence; anesthesia and mentorship; peer mentoring and training and confidence. Keyword and Boolean searches yielded 47,548 results. 360 duplicate articles were excluded. 25 were excluded based on the afore mentioned criteria. 109 articles were screened for inclusion. The remaining articles were collected through review of references from selected articles. Primary studies and systematic reviews that discussed mentor training in relation to mentor confidence levels were ranked highest for selection. The search yielded 20 articles, spanning from 2004 to 2020, which were most relevant to the focal points of mentor training and confidence. The PICO (population, intervention, comparison, outcome) inclusion criteria was utilized for selection of relevant studies. Mentorship programs best-practices and consensus is lacking which is a likely explanation for criteria variation. Fortunately, many aspects of mentoring are applicable across a wide range of disciplines. However, a lack of studies specific to the PICO resulted in the expansion of search criteria. The literature review criteria expansion featured the population of SRNAs in addition to medical students, registered nurses, surgical THE EFFECT OF ONLINE PEER MENTOR TRAINING 9 department chairs, nursing students, research mentors, and faculty mentors. Interventions of included studies featured various teaching methodologies such as workshops, online learning, seminars, and discussion. Excluded studies featured topics of preceptor training, preceptor studies, disease related mentorship programs (i.e. HIV, spinal cord injury, substance use disorder, diabetes, breast cancer), mentee training, and peer teaching. Sources were primarily obtained from the PubMed database with supplemental use of Google Scholar and EBSCOhost. A Microsoft Excel based literature matrix was used for article summary, organization, and comparison. The articles were scanned for recurring themes and mentor teaching programs were compared. Selected articles were saved on a computer hard drive. Literature Themes The characteristics of mentorship programs vary widely across institutions and professions. These variations span the topics of training, structure, institutional support, peer matching, and resource availability (Nick et al., 2012). Literature describing the effects of peer mentor training on mentor confidence is limited. Few studies have explored the effects of formal mentor training on student registered nurse anesthetists (SRNAs) (Pallaria et al., 2019; Chipas et al., 2012). This demonstrates a gap in literature specific to improving mentor confidence levels through mentor training for SRNAs. Despite this gap, the review of literature supports the claim that mentor confidence is essential to a successful mentoring relationship. The literature also supports formal mentor training as an effective means to improve mentor confidence and competence. Peer Support THE EFFECT OF ONLINE PEER MENTOR TRAINING 10 SRNAs have suggested peer support within anesthesia programs as a mechanism to reduce anxiety and improve overall well-being (Chipas et al, 2012). Peer support can be achieved through peer mentoring. Andre et al. (2017) utilized a vertical, or peer mentoring program that featured senior medical students mentoring junior medical students. Studies with similar mentoring structures showed reduced anxiety levels, increased student satisfaction, and improved mentee confidence with peer mentorship programs (Andre et al., 2017; Lewis et al., 2016; Sprengel & Job, 2004). However, attitudes, biases, prejudices, and lack of mentor confidence, assertiveness, communication, and defined expectations have been cited as reasons for failure in the peer-to-peer relationship (Lewis et al., 2016; Pallaria et al., 2014; Pfund et al. 2015; Sprengel & Job, 2004; Yau et al., 2020). Mentor training can enhance the mentor-mentee relationship by equipping the mentor with the tools and knowledge to avoid the common reasons for failed relationships. Training programs that focus on the qualities of effective mentors have been successful at helping navigate these challenges (Straus et al, 2013). Training and Mentor Confidence Eleven studies demonstrated improved mentor confidence as a result of mentor training. Improved confidence levels varied across several topics such as mentee professional development, facilitating mentee learning, carrying out difficult discussions, providing constructive feedback, expectation alignment, diversity, mentor skills, understanding, efficacy, knowledge, and readiness, and overall confidence (Feldman et al., 2012; Feldman et al., 2017; Kibbe et al., 2016; Lau et al., 2016; Nick et al., 2012; Osman & Gottlieb, 2018; Pfund et al., 2015; Sheri et al., 2019; Spiva et al., 2017; Tsen et al., 2012; Tuomikoski et al., 2020; Yau et al., 2020). All studies showed improved confidence levels with each of the respective topics as a result of mentor training programs. THE EFFECT OF ONLINE PEER MENTOR TRAINING 11 Formal Training Formal, also referred to as structured, mentor programs have been associated with better mentor-mentee relationships and overall program success (Fornari et al., 2014). A more regulated form of mentor teaching can prevent lapses in professionalism. Institutional support for formal mentoring programs has also been shown to improve retention rates (Nick et al., 2012). Many literature reviews and studies listed mentor training as a feature of formal programs (Fornari et al., 2014; Kibbe et al., 2016; Lau et al., 2016; Nick et al., 2012; Pallaria et al., 2019; Sheri et al., 2019; Spiva et al., 2017). Mentor training is considered an essential, best practice feature to improve the number of quality mentors within mentorship programs (Fornari et al., 2014; Kibbe et al., 2016, Nick et al., 2012; Straus et al., 2013). Training Format Several common themes for training formats were presented throughout the literature. The most popular training format utilized was workshops ranging from a single session to ten sessions (Johnson et al., 2015; Lau et al., 2016; Nick et al, 2012; Osman et al., 2018; Pfund et al., 2015; Straus et al., 2013; Varma et al., 2016; Yau et al., 2020). One study of SRNA mentor training utilized a written mentor handbook to increase mentor knowledge of roles and responsibilities (Pallaria et al., 2019). Feldman et al. (2012; 2017) and Kibbe et al. (2016) utilized the Mentor Development Program (MDP) as a method of training. This program provides uniform workshop curricula that was developed from evidence and literature review. Objectives and topics of the MDP include defining roles, rewards and challenges in mentorship, communication skills, work-life balance, diversity, academic advancement, and leadership (Feldman et al., 2012; Feldman et al., 2017; Kibbe et al., 2016). Distance and online learning were cited as other mechanisms to provide training (Nick et al., 2012; Sood et al., 2016; THE EFFECT OF ONLINE PEER MENTOR TRAINING 12 Tuomikoski et al., 2020). The online format was effective in increasing confidence with assuming the mentor role (Tuomikoski et al., 2020). Across the literature, the length of workshops or training session varied greatly from as little as three hours to several months. Other Training Themes Other recurring mentor training themes across the literature included defining role expectations, group discussion formats, and cultural competence training. Orientation to the mentor role is an essential step in the mentor education process (Nick et al., 2012; Pallaria et al., 2019; Sprengel & Job et al., 2004; Tuomikoski et al., 2020). Sprengel & Job (2004) also listed learning the qualities of a role model as an important part of mentor education. Group discussion formats were a recurring theme within the literature. Several workshops featured an interactive group setting to allow participants to discuss mentoring topics and common dilemmas (Lau et al., 2016; Pfund et al., 2015; Tsen et al., 2012; Varma et al., 2016). Problem solving, case discussions, and role play were common features of the group sessions (Pfund et al., 2015; Tsen et al., 2012; Varma et al., 2016). A lack of cultural competence is a common barrier to mentorship success and professional development (Osman & Gottlieb, 2018). Understanding cultural differences and developing cultural competency is an essential guideline to mentor training (Johnson & Gandhi, 2015; Osman & Gottlieb, 2018; Sheri et al., 2019). The Mentoring Competency Assessment (MCA) is a 26-item survey that was developed and validated by Flemming et al. (2013) to measure six core competencies of mentors. The six competencies include maintaining effective communication, aligning expectations, assessing understanding, addressing diversity, promoting professional development, and fostering independence. The MCA was utilized by Johnson & Gandhi (2015) and Lau et al. (2016) to help mentors assess their personal diversity competence, THE EFFECT OF ONLINE PEER MENTOR TRAINING 13 biases, and prejudices. Participating in Mentoring Across Differences training provided mentors with a greater sense of awareness of their own assumptions and biases, as well as increased their confidence in carrying out difficult conversations (Osman & Gottlieb, 2018). Mentoring can provide benefits to the mentor and the mentee. Training can develop the beneficial skills associated with mentorship. Potential benefits of mentoring include increased confidence, satisfaction, communication and academic productivity (Andre, et al., 2017, Feldman et al., 2012; Lewis et al., 2016; Sheri et al., 2019). Peer mentors have reported the mentoring experience as rewarding (Andre et al., 2017). It boosts mentors self-confidence by allowing them to see their progression from novice to expert (Sprengel & Job 2004). Long-term benefits for mentors include increased effectiveness, promotions, awards, and grants (Sheri et al., 2019). Feldman et al. (2012) found that graduates of the MDP program had sustained confidence in their mentoring skills after three years. The mentoring relationship is a highly complex relationship that has the potential to be beneficial to both the mentor and mentee. However, many potential obstacles threaten successful mentorships. Implementation of a formal mentor training program could equip mentors with the skills and resources to recognize and navigate these threats. Institutional support, mentor participation and mentee cooperation are important considerations in the development and implementation of such training programs. However, all these stakeholders could reap the benefits of a well-developed mentorship with a formal training program. Theoretical Framework Model The National League for Nursing and Johnson and Johnson provided funding for the development of a model for mentoring in nursing education (Nick et al., 2012). Nick et al. (2012) defined mentoring as a paired, reciprocal relationship between an experienced, knowledgeable THE EFFECT OF ONLINE PEER MENTOR TRAINING 14 mentor and a less experienced mentee. The model titled Best Practices in Academic Mentoring: A Model for Excellence, provides best practice guidelines for the development of formal mentorship programs (Nick et al., 2012). The model features a multifaceted approach to program development through six best practices identified as matched dyads, establishment of goals and purpose, relationship solidification, advocacy and guidance, culture integration, and resource mobilization. Mentoring program best practices provide the foundation and support to the four pillars of excellence for academic nurse mentoring outcomes. The responsibilities and outcomes of mentorship are encompassed within the four pillars of excellence. Outcome pillars include orientation to the role, socialization, skill development, and growth of future leaders in nursing and education (Nick et al., 2012). See Appendix A. This model was selected as a framework for development and implementation of a formal mentor training program. Matched Dyads Matching mentors and mentees to provide an appropriately fitting relationship is an important aspect of mentorship programs. However, the evidence is lacking about the best method for pair matching. Matching can occur through specific or arbitrary criteria, mentee preference, mentor preference, or random assignment (Nick et al., 2012). When mentoring programs obtain input from mentorship participants, mentor relationships have better communication, commitment, perceived relationship quality, and understanding of the mentor program (Nick et al., 2012). Consideration of background, age, personality, and interests may prove useful when pairing to prevent mismatched perceptions (Nick et al., 2012). Goals and Purpose Nick et al. (2012) emphasized goal establishment early in the mentorship relationship to provide clarity and direction for both participants. The goals should be specific to the needs and THE EFFECT OF ONLINE PEER MENTOR TRAINING 15 outcomes of the mentee. The most important expectations to address in the goals are reciprocity, time commitment, and planning growth activities (Nick et al., 2012). Reciprocity is important to give each member of the relationship the opportunity to provide feedback and experience the benefits of the relationship. Both parties should be given the opportunity to identify their goals and identify their purpose in mentorship. Defining these characteristics of the relationship will foster commitment from both individuals. Specifying the time commitment clarifies expectations and provides a realistic timeline for goals to be met. Regular interaction and mentorship activities performed over time solidifies the relationship engagement and commitment. Solidifying the Relationship The mentorship pair should strive to deepen the relationship through four main strategies: collaboration, regular communication, feedback exchange, and building a mutually supportive environment. Establishing a mutual trust and respect are essential to the application of these strategies. A sense of connection is highly important to a successful mentoring relationship and can be best achieved through regular communication (Nick et al., 2012). Advocacy and Guidance Mentors are in a unique position to support the mentee through advocacy. They can represent the mentees perspective and provide a global view of the situation through their own experience and organizational understanding (Nick et al., 2012). Advocacy and guidance can be achieved through providing psychosocial support, encouraging work-life balance, and career advising. Providing motivation and moral support have proven to be important in the psychosocial support of mentees and is highly valued by mentees. Culture Integration THE EFFECT OF ONLINE PEER MENTOR TRAINING 16 Nick et al. (2012) have discovered that integration into the culture can be achieved through two activities. Firstly, the mentor should teach the mentee networking skills to help them establish relationships and contacts. Networking can provide the mentee with opportunities to advance his or her career and provide knowledge of the various available resources. Secondly, the mentor can facilitate socialization through orientation to the social structure and culture of the environment or organization. Resource Mobilization Institutional resources are essential to the success of the mentorship relationship. Administrative commitment and support are critical to the development of formal mentoring programs and lack of support may be detrimental to the program and its participants. Training programs are a resource that can increase the knowledge and efficacy of mentors. Institutionally driven mentor training workshops are considered a best practice in effective mentoring. These workshops increase the number and quality of mentors available within the institution (Nick et al., 2012). Objectives The goal of this quality improvement project was to provide a self-guided, formal online mentor training program. Objectives of the training program were to improve mentors overall confidence by providing training about mentor skills including effective communication, aligning expectations, assessing the mentees' level of understanding and independence, navigating diversity and cultural competency, and professional development strategies. The expected outcome was improvement of mentors self-confidence level overall and with each of these skills. Project Design THE EFFECT OF ONLINE PEER MENTOR TRAINING 17 Using the theoretical model as a guide, the goal was to design and implement a quality improvement project through an online learning workshop. Pre and post workshop intervention surveys were issued to participants to collect quantitative data and compare the participants confidence levels pre and post intervention. Due to the COVID-19 pandemic, online workshop module development was the most efficient, safe, and practical way to educate participants. Project Site and Population The culture of the mentoring program, prior to the implementation of the quality improvement project was student-run, self-guided, and informal with minimal institutional input or support. The quality improvement project was conducted at a small, privately funded, Midwestern university. Prior to the improvement project, dyad matching and an informal introduction were provided through the current mentoring program. All students in this doctoral program were expected to mentor unless they express an explicit wish to opt out of the mentorship program. The population was comprised of 38 graduate students enrolled in the Doctor of Nursing Practice, Nurse Anesthesia program. These 38 students spanned two cohorts of nurse anesthesia student mentors. All 38 were invited to participate in the voluntary mentor training workshop. Due to the self-guided and voluntary nature of the quality improvement project, active participation and attrition were two barriers to the project. Weekly reminder emails were sent to the population to recruit learners and keep enrolled students on track to finish within the three-week course period. Method Thirty-eight students from two cohorts of the nurse anesthesia program were invited to enroll in the online Mentor Training Workshop via Canvas. The mentor training workshop featured education about mentorship best practices for developing a successful mentoring THE EFFECT OF ONLINE PEER MENTOR TRAINING 18 relationship (Nick et al., 2012). Participants began by assessing their pre-workshop confidence level through an adapted version of the MCA survey. The survey link was accessed through a hyperlink at the end of the informed consent letter (Appendix B) and directed volunteer participants to the Qualtrics survey site. Quantitative data was collected through the Qualtrics software. Participants were granted self-guided and self-paced access to the workshop modules with a deadline of three weeks. The workshop entitled SRNA Mentor Training consisted of four education modules based on objectives criterion. The four modules were centered on best practice mentoring skills including communication and expectations, assessing expectations and understanding, diversity, and professional development. Learning was augmented through videos, graphics, handouts, external resource websites, two discussion boards, and one selfreflection activity. Upon completion of the workshop, participants were asked to take the postsurvey. Pre and post-survey data was analyzed to determine if the workshop intervention improved the participants self-confidence levels. Measurement Instruments Self-awareness is an essential component of effective mentors. Understanding biases, levels of cultural competency and other potential barriers is the first step in becoming a successful mentor. In order to measure the outcomes for this project, the Mentoring Competency Assessment tool was used to measure these competencies and assist mentors assessment of their personal diversity competence, biases, and prejudices (Johnson & Gandhi, 2015; Lau et al., 2016). The original MCA survey was adapted to specifically assess mentors confidence level with the various mentoring skills. It was also adapted to be applicable to peer mentors instead of research mentors. The pre and post workshop survey MCA adaptation entitled Mentor Competency Assessment - SRNA adaptation (Appendix C) was used to determine participants THE EFFECT OF ONLINE PEER MENTOR TRAINING 19 confidence level with various mentoring skills. These skills were categorized by the key concepts of maintaining effective communication, assessing expectations and understanding, fostering independence and navigating differences, and professional development. Survey measurement of confidence on a Likert scale provided qualitative data measurement for each criterion. The Likert scale ranged from 1 being not confident at all, 4 being moderately confident with this skill, and 7 being extremely confident with this skill. Data Collection Procedure Anonymous online survey data was collected through the Qualtrics platform which was utilized for data collection and analysis. Qualtrics is an online survey platform utilized to design, distribute, and analyze survey questionnaires. Exported data was sent to Microsoft Excel and IBM SPSS software for further data analysis and storage. SPSS provides a platform for advanced statistical analysis and descriptive statistics. Data collection and analysis was primarily performed by this author. Due to the ordinal data from the Likert scale, a non-parametric version of the T-test was utilized. The Wilcoxon paired test examines the null hypothesis which states there is no difference in the median of the pre and post surveys. The mean confidence scores for each mentoring skill, as reported by participants on a Likert scale, was calculated and analyzed for changes between pre and post survey. Demographic information was also compared and analyzed for tendencies and correlations. Ethical Considerations/Protection of Human Subjects This is a quality improvement educational project within one institution; therefore, it features minimal risk to the participants. It was unnecessary to access protected personal health information and vulnerable populations were not included in the study. Due to the nature of the project, Marians Institutional Review Board granted exempt status approval (Appendix D). THE EFFECT OF ONLINE PEER MENTOR TRAINING 20 Participants were informed of the risks and benefits of participation through the informed consent letter that was sent upon invitation to the project. Timeline An Excel adapted version of the Gantt chart was utilized to keep a project timeline and meet important deadlines. The timeline spanned initial approval of the topic, project development, implementation, data analysis, and final revisions. Data Analysis and Results Demographics Of the 38 individuals invited to participate in the SRNA Mentor Training Workshop, 14 mentors completed the training and required surveys. However, two sets of survey data had to be excluded because errors in data entry by the participant would not allow the pre and post survey data to be matched. This yielded a sample size of twelve mentors (n=12). Eight participants were from the 2022 cohort and the remaining four were from the 2023 cohort. Seven participants had never received any type of formal mentor training in the past. Those who had received formal mentor training reported an average of 9.2 hours of training. The average years of experience for those who had mentoring experience was 1.3 years. Descriptive Statistics The mean scores for each of the mentoring skills measured pre and post is reported in Appendix E. The mean results show participants reported improvement in their confidence with all mentoring skills across the four main concepts of mentoring that was addressed in the mentor training workshop. The skills that showed the largest improvement in the mean scores include helping others acquire resources, helping others navigate a path to independence, helping others network, stimulating the creativity of others, and recognizing your own biases and prejudices THE EFFECT OF ONLINE PEER MENTOR TRAINING 21 (improvement of +1.58, +1.41, +1.37, +1.33, and +1.25 respectively). The standard deviations across these five skills were less than or equal to 1.25 indicating a relative similarity among participants self-reported confidence score. Helping others acquire resources and helping others network were skills addressed in the professional development module of the course. The skills of helping others navigate a path to independence and stimulating others creativity were addressed in the assessing understanding and independence module. Biases and prejudice recognition was addressed in the diversity module. Although the mean score difference between pre and post results were not as drastic, several other skills displayed improvement and a standard deviation <1.00 in the post mean score. These skills were helping others navigate a path to independence, building the confidence of others, utilizing strategies to enhance others knowledge, stimulating others creativity, acknowledging others independence, and working with others from different backgrounds (standard deviation of 0.89, 0.89, 0.9, 0.94, 0.95, 0.97 respectively). These standard deviations suggest that respondents post workshop scores were distributed closely around the same rating on the Likert scale of seven. This could suggest that the training brought all participants to a certain level of confidence with these skills regardless of their experience level prior to the training. Inferential Statistics A Wilcoxon paired test was performed to assess the statistical significance between the participants overall confidence with mentoring and overall confidence in their ability to meet the mentees expectations pre and post workshop. See Appendix F. Regarding participants overall confidence level with mentoring, the pre survey mean was 4.00 with a standard deviation of 1.414. The post survey mean was 4.92 with a standard deviation of 0.996. An initial analysis of the mean indicates a positive improvement of 0.92 between pre and post intervention. According THE EFFECT OF ONLINE PEER MENTOR TRAINING 22 to the ranks data, eight individuals displayed improved overall confidence levels when comparing pre and post data. There were three individuals who showed no difference, and one who showed a decline in their pre and post scores when responding to this question. The statistical significance for this question was 0.018. Because this value is less than 0.05, the null hypothesis is rejected indicating that there is a statistical difference between participants overall confidence level pre and post formal online mentor training. The mean for participants overall ability to meet mentees expectations was 4.00 pre survey with a standard deviation of 1.414. The post survey mean for this question was 5.17 with a standard deviation of 1.193. The difference in means pre and post (+1.17) indicates an improvement in the mean for this question. Ranks data indicated nine individuals displayed improved confidence scores in response to their overall ability to meet mentees needs. There were two reports of no improvement, and one report of a decline between pre and post intervention for this question. The statistical significance was 0.009 indicating rejection of the null hypothesis. There is a strong statistical significance in the participants overall confidence in their ability to meet the expectations of their mentees when comparing pre and post intervention results. Discussion This quality improvement project has several limitations. The literature and concepts utilized for project design displayed variations in the studied program groups such as medical residents, nursing, faculty, etc. making it difficult to generalize findings and apply them to this discipline. Findings in the literature were rarely specific to peer mentors, SRNAs, or graduate students. This project was designed for and implemented at a single university. Learning was self-guided, and the level of learner participation was not measured. Few individuals participated THE EFFECT OF ONLINE PEER MENTOR TRAINING 23 in the reflection and discussion portions of the training. Due to a small sample size, it may be difficult to generalize results across other universities. Mentors prior participation in formal mentor training could have also partially skewed results. Further study among other, larger cohorts at this and other universities could provide more generalizable results. However, most aspects of mentorship are applicable across various fields of study. Further studies could select participants who have never undergone formal mentor training. The MCA was originally designed for mentors who were already professors mentoring students. The MCA was adapted with permission from University of Wisconsin- Madison for use during this quality improvement project. A copy of this permission letter is found in Appendix G. Adaptation to specifically meet the needs of this quality improvement project compromised the validity of the MCA scale. Many measures of mentorship success are qualitative which makes them difficult to study and measure. Mentorship is complex and can be tailored the needs and preferences of the mentor and mentee. More research needs to be done to determine if a streamlined formal training could benefit mentors across disciplines. Several strengths of the quality improvement were also noted. The study measured 25 skills across four competency categories. Most individuals showed a positive improvement in their confidence with one or more mentoring skills. Most participants displayed improved overall confidence levels between pre and post intervention. Conclusion Although a peer mentor program for SRNAs was present, it lacked the structure and resources needed to develop and support the mentor-mentee relationship. This mentoring relationship is often underdeveloped and underutilized. This is likely because students assigned as mentors often lack the knowledge, skills, and confidence to be an effective peer mentor. THE EFFECT OF ONLINE PEER MENTOR TRAINING 24 Providing mentors with formal online workshop demonstrated the ability to provide an education about the basics of mentoring as a means to improve mentor confidence levels. The hope is through this improved confidence mentors will be empowered to create more meaningful relationships with their mentees. These relationships provide long-lasting benefits for both parties as they progress through their graduate degree and their anesthesia career. THE EFFECT OF ONLINE PEER MENTOR TRAINING 25 References Andre, C., Deerin, J., & Leykum, L. (2017). Students helping students: Vertical peer mentoring to enhance the medical school experience. BMC Research Notes, 10(1), 176. https://doi.org/10.1186/s13104-017-2498-8 Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). 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Journal of Clinical Nursing, 29(5-6), 684705. https://doi.org/10.1111/jocn.15127 Sheri, K., Too, J., Chuah, S., Toh, Y. P., Mason, S., & Radha Krishna, L.K. (2019). A scoping review of mentor training programs in medicine between 1990 and 2017. Medical THE EFFECT OF ONLINE PEER MENTOR TRAINING 28 Education Online, 24(1). https://doi.org/10.1080/10872981.2018.1555435 Sood, A., Tigges, B., & Helitzer, D. (2016). Mentoring early-career faculty researchers is important-but first "Train the Trainer". Academic Medicine: Journal of the Association of American Medical Colleges, 91(12), 15981600. Spiva, L., Hart, P. L., Patrick, S., Waggoner, J., Jackson, C., & Threatt, J. L. (2017). Effectiveness of an evidence-based practice nurse mentor training program. Worldviews on Evidence-Based Nursing, 14(3), 183191. https://doi.org/10.1111/wvn.12219 Sprengel, A. D., & Job, L. (2004). Reducing student anxiety by using clinical peer mentoring with beginning nursing students. Nurse Educator, 29(6), 246250. https://doi.org/10.1097/00006223-200411000-00010 Straus, S. E., Johnson, M. O., Marquez, C., & Feldman, M. D. (2013). Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Academic medicine: Journal of the Association of American Medical Colleges, 88(1), 8289. https://doi.org/10.1097/ACM.0b013e31827647a0 Tsen, L.C., Borus, J.F., Nadelson, C.C., Seely, E.W., Haas,A., & Fuhlbrigge, A.L. (2012). The development, implementation, and assessment of an innovative faculty mentoring leadership program. Academic Medicine: Journal of the Association of American Medical Colleges, 87(12), 17571761. https://doi.org/10.1097/ACM.0b013e3182712cff Tuomikoski, A. M., Ruotsalainen, H., Mikkonen, K., Miettunen, J., Juvonen, S., Sivonen, P., & Kriinen, M. (2020). How mentoring education affects nurse mentors' competence in mentoring students during clinical practice: A quasi-experimental study'. Scandinavian Journal of Caring Sciences, 34(1), 230238. https://doi.org/10.1111/scs.12728 Varma, J. R., Prabhakaran, A., Singh, S., Singh, P., Ganjiwale, J., & Pandya, H. (2016). THE EFFECT OF ONLINE PEER MENTOR TRAINING 29 Experience of a faculty development workshop in mentoring at an Indian medical college. The National Medical Journal of India, 29(5), 286289. http://www.nmji.in/temp/NatlMedJIndia295286-521249_142844.pdf Yau, B. N., Chen, A. S., Ownby, A. R., Hsieh, P., & Ford, C. D. (2020). Soliciting feedback on the wards: A peer-to-peer workshop. The Clinical Teacher, 17(3), 280285. https://doi.org/10.1111/tct.13069 THE EFFECT OF ONLINE PEER MENTOR TRAINING 30 Appendix A Theoretical Model The model: Best Practices in Academic Mentoring: A Model for Excellence. Fourth Cohort, NLN/Johnson & Johnson Faculty Leadership and Mentoring Program. (Nick et al., 2012) THE EFFECT OF ONLINE PEER MENTOR TRAINING 31 Appendix B Online Survey Informed Consent Form You are invited to participate in a research study titled The Effect of Online Formal Peer Mentor Training on Mentor Self-Confidence. This study is being conducted by Angelica Hughes, a doctoral student in the nurse anesthesia track at Marian University. As a DNP-Nurse Anesthesia student of Marian University, you are invited to participate in this study. This form is part of a process called informed consent to allow you to understand the study before deciding whether to take part. Background Most student registered nurse anesthetists (SRNAs) report stress levels that they believe negatively affect their general well-being. SRNAs have listed peer support as a top suggestion for improvement in anesthesia programs to increase well-being. Mentorship provides an opportunity to reduce student stress by providing an empathetic resource who is experienced with the academic and clinical environment. Students will be mentoring their peers during the SNRA program and later, as part of the CRNA role. However, students assigned as mentors may lack the knowledge, skills, and attitudes to be an effective, confident peer mentor. The purpose of this research study is to determine whether a formal, online educational experience in mentoring will improve mentors confidence in their mentoring abilities by providing them with a formal, online education experience. It will provide a variety of resources and exercises to improve the mentors understanding, skills, and confidence with the mentoring relationship. Procedures If you agree to be in this study, you will be asked to: Complete a 15-question, online survey related to your experience as a mentor. You will be asked to rate your confidence in your abilities to perform various mentoring skills. Complete an online training workshop. This workshop is self-paced, however please complete the full workshop August 6, 2021. Completion of the workshop will take about 45 minutes. After completion of the training, you will complete a second version of the survey. This version of the survey has the demographic questions removed and will take less time to complete. Voluntary Nature of the Study: This study is voluntary. Everyone will respect your decision of whether you choose to participate in the study or not. No one at Marian University or in the DNP Program will treat you differently if you decide not to be in the study. If you decide to join the study now, you can still change your mind later. You may stop at any time. Risks and Benefits of being in the Study: Being in this type of study involves some risk of the minor discomforts that can be encountered in daily life such as fatigue. Being in this study would not pose risk to your safety or wellbeing. Potential benefits include improved confidence with mentoring skills and improved mentoring relationships. The knowledge gained through mentor training will contribute to the advancement of your professional development. These professional development benefits may THE EFFECT OF ONLINE PEER MENTOR TRAINING 32 include increased effectiveness, academic productivity, satisfaction, and confidence. Study results will also assist in preparing future mentors and further development of the mentorship program at Marian University. All students and instructors in the DNP program will have access to the summary of the results of the study. Payment: You will not receive payment for your participation in the study. Privacy: Any information you provide will be kept confidential. The researcher will not use your personal information for any purposes outside of this research project. Also, the researcher will not include your name or anything else that could identify you in the study reports. Data will be kept secure by storing it in a password-protected computer hard-drive kept in the home of the researcher in addition to a flash-drive that will be retained in a fire-proof lock box which can be accessed by the researcher alone. Data will be kept for a period of at least 5 years, as required by the university. Contacts and Questions If you have any questions, you may contact the researcher via phone at (765) 592-1580 or email at ahughes734@marian.edu. If you want to talk privately about your rights as a participant, you may contact Dr. Amanda Egan, Chair of the Marian University Institutional Review Board, to discuss this with you. Please print or save this consent form for your records. Statement of Consent: I have read the above information and I feel I understand the study well enough to make a decision about my involvement. By proceeding with the pre-workshop survey, you are indicating that you are at least 18 years old, have read, understand the consent form, and agree to participate in this study. THE EFFECT OF ONLINE PEER MENTOR TRAINING Appendix C Mentor Competency Assessment - SRNA adaptation 33 THE EFFECT OF ONLINE PEER MENTOR TRAINING 34 THE EFFECT OF ONLINE PEER MENTOR TRAINING Appendix D 35 THE EFFECT OF ONLINE PEER MENTOR TRAINING 36 Appendix E Mean Scores All Mentoring Skills Maintaining Effective Communication Active listening Providing constructive feedback Establishing a trusting relationship Accommodating communication styles Employing strategies to improve communication Coordinating with others effectively Communicating clear expectations within a professional relationship Assess Expectations and Understanding Aligning expectations Considering personal and professional differences Working with other to set goals Helping others develop strategies meet goals Estimating others level of knowledge Employing strategies to enhance others knowledge and abilities Fostering Independence and Navigating Differences Motivating other Building others confidence Stimulating others creativity Pre survey Mean score (Standard deviation) 5.42 (1.31) 4.83 (1.19) Post survey Mean score (Standard deviation) 5.58 (1.16) 5.50 (1.09) Difference (change in pre vs post mean) 5.25 (1.29) 5.67 (0.98) +0.42 4.50 (0.97) 5.25 (1.31) +0.7 4.58 (1.31) 5.50 (1.00) +0.9 5.25 (1.14) 5.50 (1.00) +0.2 5.33 (1.23) 5.58 (1.16) +0.25 4.42 (1.24) 4.50 (1.38) 5.58 (1.00) 5.58 (0.79) +1.16 +1.08 5.42 (1.24) 5.83 (1.27) +0.41 4.83 (1.34) 5.17 (1.03) +0.34 3.92 (1.62) 5.00 (1.13) +1.08 4.00 (1.35) 5.08 (0.90) +1.08 4.50 (1.17) 4.75 (1.14) 5.58 (1.08) 5.33 (0.89) +1.08 +0.58 3.67 (1.61) 5.00 (0.95) +1.33 +0.16 +0.67 THE EFFECT OF ONLINE PEER MENTOR TRAINING Acknowledging others contributions Helping others navigate a path to independence Recognizing your own biases and prejudices Working effectively with others from different backgrounds Professional Development Helping others network Helping others set career goals Helping others balance work/life Understanding your impact as a role model Helping others acquire resources 37 5.17 (0.94) 5.83 (0.94) +0.66 3.92 (1.44) 5.33 (0.89) +1.41 4.00 (1.41) 5.25 (1.22) +1.25 4.92 (1.56) 5.75 (0.97) +0.83 3.33 (1.56) 4.08 (1.73) 4.70 (1.14) 5.25 (1.06) +1.37 +1.17 4.08 (1.24) 5.17 (1.40) +1.09 4.50 (1.24) 5.58 (1.00) +1.08 3.92 (1.51) 5.50 (1.00) +1.58 THE EFFECT OF ONLINE PEER MENTOR TRAINING Appendix F Wilcoxon Test Inferential Statistics Overall confidence level Overall ability to meet mentees expectations 38 THE EFFECT OF ONLINE PEER MENTOR TRAINING 39 Appendix G Permission Letter from University of Wisconsin- Madison From kcspencer2@wisc.edu 1/14/2021 12:40 PM Dear Angelica, Thanks for contacting our team! Yes, you have permission to use our pre and post instruments. We just ask that you acknowledge our work by providing the citation to the Mentor Competency Assessment (MCA) manuscript and indicating that the instrument was adapted, if applicable. Fleming M, House S, Shewakramani Hanson V, Yu L, Garbutt J, McGee R, Kroenke K, Abedin Z, Rubio D.M. The mentoring competency assessment: Validation of new instrument to evaluate skills of research mentors. Acad Med. 2013;88(7):1002-1008. The MCA in its current form has been validated; while you may remove and/or edit items, doing so will invalidate the scale. If you are planning to create asynchronous educational modules, I would also like to share a link to the online course developed by our colleagues at the University of Minnesota: Optimizing the Practice of Mentoring. https://www.ctsi.umn.edu/education-and-training/mentoring/mentor-training This online module is freely available (you just need to create a guest account with the university) and may be useful as you develop your project. Best regards, Kim Kim Spencer, MS Assistant Director, Research & Evaluation National Research Mentoring Network Coordination Center https://nrmnet.net Center for the Improvement of Mentored Experiences in Research (CIMER) http://cimerproject.org/ Institute for Clinical and Translational Research (ICTR) https://ictr.wisc.edu/mentoring/ University of Wisconsin-Madison School of Medicine and Public Health 2112 Health Sciences Learning Center 750 Highland Avenue | Madison, WI 53705  ...

... IMPROVING SIMULATION TRAINING Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2022 Improving Simulation Training: Rapid Sequence Induction with a Debriefing Component Kelsey S. Downham Marian University Leighton School of Nursing Chair: Bradley Stelflug, DrAP, MBA, CRNA _________________________ Date of Submission: November 8th, 2021 1 IMPROVING SIMULATION TRAINING 2 Table of Contents Abstract4 Introduction..6 Background...6 Problem Statement........7 Organizational Gap Analysis of Project Site.....8 Review of the Literature..9 Search Methodology.....9 Simulation.....9 Knowledge/Confidence...11 Debriefing...13 Theoretical Framework......14 PEARLS Debriefing Framework14 Goals, Objectives, and Expected Outcomes..14 Project Design15 Project Site and Sample..15 Methods...16 Measurement Instruments...17 Student Satisfaction and Self-confidence Survey...17 Knowledge Assessment..17 Data Collection and Analysis..17 Results18 Demographics.18 IMPROVING SIMULATION TRAINING 3 Satisfaction Subscale..19 Self-confidence Subscale20 Knowledge Test..21 Discussion..24 Strengths and Limitations...24 Implications for Practice and Future Research...24 Conclusion.25 References..25 Appendix A31 Appendix B34 Appendix C35 Appendix D36 Appendix E37 Appendix F.38 IMPROVING SIMULATION TRAINING 4 Abstract Background: Simulation based training continues to be a growing element of healthcare education. Simulation training allows student registered nurse anesthetists (SRNAs) to practice critical skills in a low stress environment. Implementing simulation education with an evidencebased framework can improve educational outcomes. Simulation debriefing has been proven to be a key component of simulation education. The Promoting Excellence and Reflective Learning in Simulation (PEARLS) model can be used as a framework to implement a formal debriefing component to simulation training. Purpose: The purpose of this project was to add the PEARLS debriefing model to the current rapid sequence induction (RSI) simulation at Marian University, and determine if this addition improved knowledge, confidence, and satisfaction of first year SRNAs. Methods: This project utilized a quality improvement design. Quantitative data was collected using the 13-question National League for Nursing (NLN) Survey and a 5-question knowledge assessment. Data was analyzed using JASP (Jeffreys Amazing Statistics Program) to determine if statistical significance occurred between the control and experimental group. Implementation Plan/Procedure: The project took place at the Marian University Evans Center Simulation Laboratory. Twenty-four first year SRNAs were randomly divided into a control group, which received current simulation education, and an experimental group, which received current simulation education with the addition of the PEARLS debriefing model. Implications/Conclusion: The implementation of the PEARLS debriefing model improved student confidence scores on the NLN Survey. Students who completed simulation training with a debriefing component rated higher self-confidence scores than students who did not receive a IMPROVING SIMULATION TRAINING debriefing component (p = 0.005). A formal debriefing component should be added to the rapid sequence induction simulation training at Marian University. Keywords: Rapid sequence induction, simulation, simulation-based training, confidence, knowledge, satisfaction, debrief, debriefing component. 5 IMPROVING SIMULATION TRAINING 6 Improving Simulation Training: Rapid Sequence Induction with a Debriefing Component This project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. The Marian University Nurse Anesthesia Program currently offers a simulation training course to first year doctoral students in preparation for the transition into the clinical setting. This class includes hands-on simulation training with high-fidelity mannequins. The course aims to prepare student registered nurse anesthetists (SRNAs) for real clinical scenarios by providing education and practice on a variety of intricate clinical skills. The vital skill of performing a rapid sequence induction (RSI) is currently taught in the simulation course. The current simulation education and training on an RSI is sufficient at Marian University but does not include a debriefing component. This project aims to improve the confidence, satisfaction, and knowledge of first year SRNAs by implementing an RSI simulation with the addition of the PEARLS debriefing model. Background It is imperative that SRNAs take information learned in didactic courses and apply it into the clinical setting. This transition often requires hands on practice through simulation training. Anesthesia programs and anesthesia educators continuously seek to improve students skill level, confidence, and knowledge through simulation experiences. By knowing how to provide the best simulation education and the benefits of simulation training, anesthesia educators can appreciate and improve the transfer of learning (Botma, 2014). An important skill first year SRNAs must learn and practice before entering the clinical setting is how to perform an RSI. This fundamental airway skill is used frequently by anesthesia providers. An RSI is an intubation technique that is indicated for patients who are at risk of IMPROVING SIMULATION TRAINING 7 aspiration (Mollalign et al., 2019). For example, when emergently anesthetizing a patient for a surgery, and the patients fasting status is unknown, performing an RSI is the safest method to protect and secure the airway. An RSI is a critical technique that involves securing the airway by doing so in a manner that lowers the risk of pulmonary aspiration (Mollalign et al., 2019). Being able to perform this skill diligently can lead to better patient outcomes. An RSI practiced with an inappropriate technique can lead to hypoxia, pulmonary aspiration, failure to intubate, and even patient death (Mollalign et al., 2019). It is critical that nurse anesthesia programs strive to better students knowledge and confidence level prior to entering the clinical arena. Improved knowledge and confidence can lead to better human performance and higher quality patient care (Kalaniti & Campbell, 2015; Wiggins et al., 2018). With todays advancements in technology, mannequins can provide hands-on experience that can help prepare SRNAs for the clinical practice setting. Simulation training has been shown to improve the confidence and knowledge of nursing students (Botma, 2014). According to Berragan (2014), simulation training was found to provide assurance and identity to students. In anesthesia residents, the use of simulation has been found to be a reliable method to assess student performance (Schwid et al., 2002). However, additional research is needed to evaluate the effectiveness of simulation training in anesthesia residents (Schwid et al., 2002). Advancements to RSI simulation training could offer better education and increase knowledge, satisfaction, and confidence of first year SRNAs at Marian University. Problem Statement Significant patient complications can occur from lack of appropriate training and knowledge on how to complete an RSI. First year SRNAs must be prepared to perform this technique proficiently when entering the clinical setting. The use of simulation training allows IMPROVING SIMULATION TRAINING 8 students to practice hands on clinical scenarios within an environment of safety. However, additional research is needed to determine the best way to provide simulation training (Schwid et al., 2002). The Marian University Nurse Anesthetist Program currently lacks a formal debriefing component in its simulation training on an RSI. The question addressed by this project was: In first year SRNAs, how does the training of a rapid sequence induction simulation with a debriefing session, compared to current rapid sequence induction simulation training, affect the knowledge, confidence, and satisfaction of Marian University students? Gap Analysis Marian Universitys Nurse Anesthesia program currently lacks a formal debriefing component for the RSI stimulation. As the program and anesthesia educators seek to better the simulation experiences, the need for research on the best way to conduct simulation training is needed. The International Nursing Association for Clinical Simulation and Learning (INACSL) describes itself as a prestigious leader in the development of simulation training. Incorporating best practices, the INACSL offers an evidence-based, step-by-step framework to improve simulation education (INACSL, 2016). The INACSL Standards of Best Practice: Simulation Design includes providing students with a debriefing session after the simulation scenario is complete to enhance the simulation experience (INACSL, 2016). A formal debriefing session is what the Marian University Nurse Anesthesia program currently lacks in the RSI simulation. The goal of this project was to determine if the addition of a formal debriefing model to the current RSI simulation improved knowledge, confidence, and satisfaction scores among first year SRNAs at Marian University. Review of Literature Search Methodology IMPROVING SIMULATION TRAINING 9 Databases used for collecting research included PubMed, MEDLINE: EBSCO, and Google Scholar. Search terms included: simulation training, anesthesia simulation training, benefits of simulation in nursing, mannequin-based simulation, high-fidelity simulation, and rapid sequence induction simulation. Recent articles that included SRNAs and the effect of high-fidelity simulation training were scarce. Due to limited research findings on the use of high-fidelity simulation training for rapid sequence inductions among SRNAs, the use of simulation training among all levels of nursing education and skills were included in the literature review. Articles involving undergraduate nursing students, SRNAs, and certified registered nurse anesthetists (CRNAs) were included. Selected articles were published between the years 2014 and 2020, with two exceptions. The articles examined included levels of evidence I-VI and were based on the leveling system from Melnyk & Fineout-Overholt (2012). All articles obtained were presented by a reliable journal, peer-reviewed, and published in the English language. Articles were first screen by title and abstract. If these provided evidence for the simulation objectives, the full article was screened. Thirteen research articles were selected and synthesized (Appendix A). The following sections provide topics of importance that were found during the literature review. Simulation In 1969, Sim One was the first ever recorded use of a simulation mannequin to train anesthesia students (Lapkin et al., 2010). The use of simulation mannequins today can be described according to level of fidelity: low, medium, or high. Low fidelity mannequins are basic and less advanced. However, high-fidelity mannequins are life size and mimic a real patient by conveying vital signs, heart, and lung sounds. High-fidelity simulation mannequins respond the same way a patient would if given the same medications or subjected to the same external forces IMPROVING SIMULATION TRAINING 10 such as incision. The high-fidelity patient simulation mannequin used at Marian University Nurse Anesthesia Simulation Laboratory is the Laerdal SimMan Universal Patient Simulator. With todays advances in technology, high-fidelity simulation has become a part of healthcare education over the past decade (Kalaniti & Campbell, 2015). Simulation offers medical educators the opportunity to teach students essential clinical skills in a safe environment (Kalaniti & Campbell, 2015). This new way of preparing healthcare students has initiated questions to the field of medical education. There is no better time to explore the benefits of simulation education and benefits for students (Kalaniti & Campbell, 2015). Many authors have conducted research to determine the use of simulation-based training and its influence on nursing education. Thirteen peer reviewed research articles were used to determine the effectiveness of simulation training among nursing students. According to Hayden et al., the first and largest, longitudinal, randomized controlled trial was conducted in 2014 to determine if simulation training can be equally substituted for traditional clinical experience in undergraduate nursing programs across the United States. With a sample size of 666 nursing students, the researchers sought to determine the effects on knowledge, clinical competency, and transferability of learning from simulation training into the clinical setting. Researchers found that up to 50% of simulation training can successfully be replaced with traditional clinical experience in undergraduate nursing students (Hayden et al., 2014). The authors also found comparable passing rates of the National Council Licensure Examination between student groups who were simulation trained and ones who attended the tradition clinical settings (Hayden et al., 2014). This article showed that simulation-based training can be just as effective as traditional clinical experience (Hayden et al., 2014). IMPROVING SIMULATION TRAINING 11 Among SRNAs, simulation has been proven to expand knowledge and enhance the performance of critical skills such as the use of transesophageal echocardiography and recognizing an intraoperative myocardial infarction (Erlinger et al., 2019; Shields & Gentry, 2020). In a study conducted on the use of transesophageal echocardiography, SRNAs who received simulation-based training in comparison to online training demonstrated improved performance in three cognitive categories of knowledge, transesophageal echocardiography windows, and cardiac pathology (Shields & Gentry, 2020). A similar study conducted on SRNAs compared the use of high-fidelity simulation and virtual simulation to determine differences in recognizing changes in a patients condition (Erlinger et al., 2019). This study showed that among second-year nurse anesthesia students, the use of high-fidelity simulation was superior to using virtual simulation. The second-year students were able to identify an intraoperative myocardial infarction faster when using high-fidelity simulation training (Erlinger et al., 2019). However, third-year nurse anesthesia students took the same amount of time to recognize changes in the patients condition. This study showed that high-fidelity simulation training is more beneficial for second year SRNAs who have had little to no clinical experience and less didactic training (Erlinger et al., 2019). Knowledge and Confidence Two important simulation training outcome measures are levels of knowledge and confidence. High-fidelity simulation was used in a study to test nurses knowledge and confidence on peripheral intravenous catheter insertion (Keleekai et al., 2016). The researchers presented the nurses with video education followed by virtual simulation then two simulationbased workshops. The study included a formative debrief after each training. This study showed IMPROVING SIMULATION TRAINING 12 that the use of simulation significantly improved the nurses knowledge and confidence for peripheral intravenous catheter insertion. Hustad et al., 2019 showed that confidence levels improved using simulation-based training by allowing nursing students to take what was learned during two high-fidelity simulation scenarios and transfer it to clinical practice. For example, participants in the study described critical clinical skills were developed during simulation that are needed for clinical practice (Hustad et al., 2019) This study also exhibited that knowledge improved through enhancing clinical skills and judgement (Hustad et al., 2019). Wiggins et al., 2018 used simulation-based training to determine the effect on knowledge, skills, and attitude towards regional anesthesia. The researchers created a blended simulation experience that included an online portion, checklists, and a simulation portion. The online portion included pre-course didactic content and consisted of seven modules, which took approximately four hours to complete (Wiggins et al., 2018). The checklist was developed based on a literature review of best practices and a modified Angoff method was used for minimum passing threshold (Wiggins et al., 2018). The simulation portion involved a realistic simulator which included the use of actual spinal and epidural kits used in the clinical setting (Wiggins et al., 2018). The use of this simulation educational approach improved knowledge, skill level, and confidence among CRNAs completing spinal and epidural blocks (Wiggins et al., 2018). A systematic review and meta-analysis conducted by Hegland et al., 2017 concluded that the use of high-fidelity simulation-based training has benefits on clinical skills. However, no conclusion could be established on the effect of knowledge. The authors noted that more research needs to be completed due to the limited number of high-quality random control trials of decent size (Hegland et al., 2017). IMPROVING SIMULATION TRAINING 13 Debriefing One aspect of simulation training emphasized by many studies reviewed was the importance of debriefing (Doherty-Restrepo et al., 2018; Erlinger et al., 2019; Hayden et al., 2014; Hustad et al., 2019; Wiggins et al., 2018). Debriefing allows students to critically reflect on performance and use constructive criticism to improve the learning experience (DohertyRestrepo et al., 2018). The INACLS also includes the debriefing process as a part of the best practices for simulation training (INACSL, 2016). In 2018, a study conducted by DohertyRestrepo et al. concluded that the use of debriefing with either peers or faculty is an effective method to promote confidence and improve clinical skills in graduate students performing a knee injury assessment. Wiggins et al., reviewed 51 studies involving the use of high-fidelity simulation. They concluded educational feedback through debriefing was the most significant aspect of simulation-based training (Wiggins et al., 2018). According to INACLS (2016), learning and reflection occur during the debriefing phase. For debriefing to be successful, five criteria must be met. First, the debriefing session must be led by a person knowledgeable in the debriefing process. Second, the setting where the debriefing takes place should be conductive to learning and support privacy and open communication. Third, the person leading the debriefing must offer attentiveness and concentration during the session. Fourth, the debriefing session must be based on a theoretical framework, which is formal. Fifth, the debriefing session must be aligned with objectives and outcomes of the simulation (INACLS, 2016). Theoretical Framework Promoting Excellence and Reflective Learning in Simulation (PEARLS) IMPROVING SIMULATION TRAINING 14 The Promoting Excellence and Reflective Learning in Simulation (PEARLS) model is recommended by the INACS and offers an evidence-based approach to implement healthcare simulation debriefing (Bajaj et al., 2018). This debriefing tool was selected as a framework for this project. According to the debriefing tool developers, debriefing sessions should include a safe learning environment, actively engage participants, and focus on learning and improvement (Bajaj et al., 2018, para 1.). This framework integrates three common educational strategies. These are learner self-assessment, focused facilitation, and providing information or direct feedback. This formal debriefing tool provided the person leading the RSI simulation debriefing session with structure, goals, and integrated an evidence-based debriefing strategy. See Appendix B and C for a visual diagram of the framework. Goal, Objectives, and Expected Outcomes The goal of this project was to enhance the confidence, knowledge, and satisfaction of first year SRNAs at Marian University in the skill of performing an RSI by adding a debriefing component to current simulation training. The objectives included adding a debriefing component to current simulation training and measuring the knowledge, confidence, and satisfaction of performing an RSI simulation. This was done through a post-test to assess knowledge and a student self-evaluation survey to assess confidence and satisfaction. The National League of Nursing (NLN) student satisfaction and self-confidence survey was used. The expected outcome was that knowledge, confidence, and satisfaction scores would improve in students who receive the PEARLS formal debriefing session after the performed RSI simulation, compared to students who do not receive structured debriefing. To achieve goals and objectives of this project, the project design was implemented during April of 2021. Project Design IMPROVING SIMULATION TRAINING 15 The research project utilized an experimental design with a convenience sample of twenty-four SRNAs who were randomly assigned to two groups of twelve and twelve. One group received current simulation training used by Marian Universitys Nurse Anesthesia Program, which does not include formal debriefing. The other group received the same simulation training with the addition of the PEARLS debriefing framework after the simulation scenario was completed. Both groups were given the same checklist prior to the simulation which was provided by the course instructor and project evaluator, Dr. Bradley Stelflug. The evaluator was responsible for grading the checklist and provided focused facilitated feedback. The DNP project investigator, Kelsey Downham, implemented the PEARLS debriefing tool. Both groups were introduced into the simulation laboratory and provided the same scenario chosen by the evaluator. Knowledge was assessed in both groups after implementing the simulation training methods. The data was collected using a post-test. Confidence and satisfaction were assessed using a student self-evaluation survey. The quantitative data was collected in both groups after simulation training was complete. Project Site The research project was conducted at the Evans Center on Marian Universitys campus. The simulation training took place in the high-fidelity simulation laboratory which included all resources needed to complete the project. Resources included a high-fidelity mannequin and appropriate intubation supplies. Persons in the simulation experience included the first year SRNA, the project investigator, and the project evaluator. The project was open to all first year SRNAs who were enrolled in the Doctor of Nursing Practice program at Marian University. Methods IMPROVING SIMULATION TRAINING 16 Twenty-four students were randomly divided into two groups of twelve. A control group received the current simulation training included in Anesthesia Principles 1-Simulation. The experimental group received the same simulation training but with the addition of formal debriefing. Demographic information was collected prior to the simulation. This included age, gender, and number of years as a registered nurse. Prior to the simulation, all students were given a reading assignment which included information on why and how to perform a rapid sequence induction. A checklist, made by the project evaluator, was provided to all students which contained required steps to pass the RSI simulation. All students were introduced into the simulation laboratory and provided appropriate supplies to complete the simulation. The students were provided with a brief patient report which included a healthy patient weighing 70 kilograms. After completion of the simulation, the control group participants then completed the post stimulation survey. The experimental group participants completed a formal debriefing session. The debriefing session included the project investigator, who led the PEARLS debriefing tool. The project evaluator implemented the focused facilitated portion of the PEARLS tool. This included discussing key aspects of the performance and reviewing the graded checklist with the student. Both groups completed a five-question post-test to assess knowledge, along with a 13question satisfaction and confidence survey. Requirements for passing Anesthesia Principles 1Simulation remained the same for both groups. The course was pass/fail and the grading checklist was developed and graded by the project evaluator. The students in the control group were offered the opportunity to redo the simulation with the debriefing component. Measurement Instrument National League for Nursing (NLN) Survey IMPROVING SIMULATION TRAINING 17 This 13-question tool examined student satisfaction and self-confidence in simulation learning (Appendix D). The series of questions assessed personal attitudes about education satisfaction with simulation learning and self-confidence. The survey included answers 1 through 5, with 1 being strongly disagree and 5 being strongly agree. Knowledge Assessment To assess knowledge, students answered five multiple choice questions regarding rapid sequence induction (Appendix E). These questions were created using the 6th edition textbook, Nurse Anesthesia by John J. Nagelhout, Sass Elisha, and Karen Plaus (2018). The questions were provided as a post-test after the simulation training. The questions were validated by anesthesia educators Dr. Bradley Stelflug, Dr. Sarah Franco, and Dr. Lee Summerland-Grady. Data Collection and Analysis Responses from the demographic survey, NLN survey and the RSI quiz were collected and analyzed. Data collection was completed by the project investigator. Demographic information was collected prior to the simulation experience. The remaining data was collected after the simulation training for the control group and after the debriefing component for the experimental group. Printed, paper surveys were utilized and placed into a folder after completion. Data collection remained anonymous and two separate folders were used for the experimental and control group. Descriptive statistics were computed using JASP (Jefferys Amazing Statistics Program). Demographic information was first analyzed and presented in a demographic table. An independent t test was then used to compare differences among the control and experimental group. A t test was chosen for assorted reasons. An independent t test can compare the means of two independent samples. Even with a small sample size, the t test can manage violations of the IMPROVING SIMULATION TRAINING 18 assumed normal distribution. The t test presented the differences in mean knowledge, confidence, and satisfaction scores. Results Demographics Twenty-four students participated in the RSI Simulation Project. Eight participants (33.3%) were male, and sixteen participants (66.7%) were female. Ages ranged from twenty-five to fifty-five years with a mean age of thirty-three. Eleven participants (46%) reported being a registered nurse for one to five years. Eight participants (33%) reported being a registered nurse for six to ten years. Five participants (21%) reported being a registered nurse for eleven years or more. Demographics Table. Demographics of 24 SRNA participants Characteristics N % Age Range 25-35 36-46 47-57 18 5 1 75.0 21.0 4.0 16 8 66.7 33.3 11 8 4 1 46.0 33.0 17.0 4.0 Sex Female Male Years of Experience as a Registered Nurse 1-5 6-11 12-17 18-23 Participant Satisfaction Participant satisfaction was tested by the NLN Student Satisfaction and Self-Confidence survey. An Independent-Samples t test was conducted to compare the mean satisfaction scores of IMPROVING SIMULATION TRAINING 19 students who received debriefing to the mean scores of students who did not receive debriefing. In Table 1-A the t is the student t-statistic which indicates the difference between the sample mean and the number to the standard error of the mean. The t-value of 1.749 is relatively small, which results in a larger p-value. The df value correlates to the degree of freedom. The SE difference of 1.381 is the difference between the sample mean and the test value. The 95% CI for mean difference represents the lower and upper bound of the confidence interval for the mean. In Table 1-B the N value represents the number of valid observations used for the t test. The presented mean is the mean of the variable. The SD is the standard deviation of the variable. The SE is the standard error mean that estimates the standard deviation of the sample mean. No significant difference was found (t(22) = 1.749, p > .05). A significant difference would have been noted with a result of p < .05. The mean of the students who received debriefing (M = 23.167, sd = 2.552) was not significantly different from the mean of the students who did not receive debriefing (M = 20.750, sd = 4.048). Data analysis for participant satisfaction is shown in table 1-A and table 1-B. Table 1-A. Independent Samples T-Test 95% CI for Mean Difference t df p Mean Difference SE Difference Lower Upper Score 1.749 22 0.094 2.417 1.381 -0.448 5.282 Table 1-B. Results of Satisfaction Scores Group N Mean Score Debriefing 12 23.167 No Debriefing 12 20.750 Participant Self-Confidence SD 2.552 4.048 SE 0.737 1.169 IMPROVING SIMULATION TRAINING 20 Participant self-confidence was tested by the NLN Student Satisfaction and SelfConfidence survey. An Independent-Samples t test was conducted to compare the mean selfconfidence scores of students who received debriefing to the mean scores of students who did not receive debriefing. In Table 2-A the t is the student t-statistic which indicates the difference between the sample mean and the number to the standard error of the mean. The t-value of 3.160 is relatively large, which results in a smaller p-value. The df value correlates to the degree of freedom. The SE difference of 1.477 is the difference between the sample mean and the test value. The 95% CI for mean difference represents the lower and upper bound of the confidence interval for the mean. In Table 2-B the N value represents the number of valid observations used for the t test. The presented mean is the mean of the variable. The SD is the standard deviation of the variable. The SE is the standard error mean that estimates the standard deviation of the sample mean. Statistical significance was found between the means of the two groups (t(22) = 3.160, p < .05). A significant difference was noted with a result of p < .05. The mean of the students who received debriefing (M = 38.083, sd = 4.231) was significantly different from the mean of the students who did not receive debriefing (M = 33.417, sd = 2.875). This showed that the implementation of the debriefing component resulted in higher self-confidence scores. Data analysis for participant self-confidence is demonstrated in table 2-A and table 2-B. Table 2-A. Independent Samples T-Test 95% CI for Mean Difference t df p Mean Difference SE Difference Lower Upper Score 3.160 22 0.005 4.667 1.477 -1.604 7.729 IMPROVING SIMULATION TRAINING 21 Table 2-B. Results of Self-Confidence Scores Group N Mean Score Debriefing 12 38.083 No Debriefing 12 33.417 SD 4.231 2.875 SE 1.221 0.830 Participant Knowledge Participant knowledge was tested by a posttest knowledge assessment. Percentage values were calculated for each question and compared between groups. Two of the five questions resulted in a twenty-five percent improvement between groups. One question resulted in an eight percent improvement. Two questions resulted in no change and were correct 100% between the two groups. An Independent-Samples t test was conducted to compare the mean knowledge scores of students who received debriefing to the mean scores of students who did not receive debriefing. In Table 3-B the t is the student t-statistic which indicates the difference between the sample mean and the number to the standard error of the mean. The t-value of 0.713 is relatively small, which results in a larger p-value. The df value correlates to the degree of freedom. The SE difference of 1.965 is the difference between the sample mean and the test value. The 95% CI for mean difference represents the lower and upper bound of the confidence interval for the mean. In Table 3-C the N value represents the number of valid observations used for the t test. The mean presented is the mean of the variable. The SD is the standard deviation of the variable. The SE is the standard error mean that estimates the standard deviation of the sample mean. No significant difference was found (t(8) = 0.713, p > .05). A significant difference would have been noted with a result of p < .05. The mean knowledge score of the students who received debriefing (M = IMPROVING SIMULATION TRAINING 22 10.400, sd = 2.302) was not significantly different from the mean of the students who did not receive debriefing (M = 9.00, sd = 3.742). Data analysis is found in tables 3-A, 3-B, and 3-C. Table 3-A. Comparison of Knowledge Assessment Scores Test Questions All the following are reasons to perform a rapid sequence induction except: a. Trauma patient (Distractor) b. Morbidly obese patient (Correct Answer) c. Patient with history of delayed gastric emptying and reports uncontrolled GERD during pre-op (Distractor) d. Pregnant women 22 weeks' gestation (Distractor) What factor provides the highest overall successful rate of airway management and greatest possibility for rapidly securing the airway? a. Use of propofol 2mg/kg (Distractor) b. Use of a stylet in the ETT (Distractor) c. Use of muscle relaxation (Correct Answer) d. Use of a Glidescope (Distractor) What has been described as the gold standard means of preventing aspiration of gastric contents during the RSI? a. Use of Succinylcholine 1.5mg/kg (Distractor) b. Providing positive pressure ventilation before administration of muscle relaxant (Distractor) c. Cricoid pressure (Correct Answer) d. Use of a laryngeal mask airway (Distractor) Without With Percent Difference Debriefing Debriefing Results Results Correct=6 Correct=9 25% improvement Incorrect=6 Incorrect=3 50% Correct 75% Correct Correct=4 Correct=7 25% improvement Incorrect=8 Incorrect=5 33% Correct 58% Correct Correct=12 Incorrect=0 100% Correct Correct=12 Incorrect=0 100% Correct No change IMPROVING SIMULATION TRAINING 23 When should cricoid pressure be released during the RSI? a. After ETT placement has been confirmed (Correct Answer) b. After administration of muscle relaxation (Distractor) c. As soon as the patient loses the eyelid reflex (Distractor) d. Whenever the nurse believes it is appropriate (Distractor) One of the greatest differences between routine induction and RSI is? a. The use of high dose Propofol (Distractor) b. The administration of a Proton Pump Inhibitor in pre-op c. The use of muscle relaxation before knowing if you can mask ventilate the patient (Correct Answer) d. Pushing induction medications quickly (Distractor) Correct=12 Incorrect=0 100% Correct Correct=12 Incorrect=0 100% Correct Correct=11 Correct=12 Incorrect=1 Incorrect=0 92% Correct 100% Correct No change 8% improvement Table 3-B. Independent Samples T-Test Scores t 0.713 df 8 p Mean Difference SE Difference 0.496 1.400 1.965 Table 3-C. Results of Knowledge Scores Group N Mean Score Debriefing 5 10.400 No Debriefing 5 9.000 SD 2.302 3.742 SE 1.030 1.673 Limitations, Recommendations, Implications for Change There were notable limitations of this project. First, the sample population from the Marian University Nurse Anesthesia program consisted of twenty-four first year students. This limitation could have been improved by a large sample size. Second, the high-fidelity mannequin was not fully functional during the time the project was implemented. The students were unable IMPROVING SIMULATION TRAINING 24 to accurately assess end tidal carbon dioxide and oxygen level after endotracheal tube placement. Therefore, this project could be repeated and potentially show more meaningful results with a fully functioning high fidelity simulator. Implications for Practice Data analysis of the RSI simulation project showed a statically significant increase in student confidence scores. This indicated that the students who received simulation debriefing rated higher self-confidence scores on the NLN survey. Improved self-confidence by simulation debriefing has also been supported by recent research (Hustad et al., 2019; Keleekai et al., 2016; Wiggins et al., 2018). To improve student self-confidence, a formal debriefing component should be added to simulation education at Marian University. The mean score of both knowledge and satisfaction were higher in the students who received simulation debriefing. However, neither knowledge nor satisfaction scores showed statistical significance. This indicates that further research is needed to determine if knowledge and satisfaction are impacted by a debriefing component. The satisfaction scores that did not show statistical significance could be because students are satisfied with simulation training regardless of debriefing. The knowledge and satisfaction of students at Marian University will not be improved with the addition of a formal debriefing component to stimulation education. Conclusion Satisfaction No significant difference was found between satisfaction scores using the NLN Nursing Satisfaction and Self-Confidence in Learning instrument. The mean of the students who received debriefing was slightly higher. However, they were not significantly different from the mean of IMPROVING SIMULATION TRAINING 25 the students who did not receive debriefing. This data shows that debriefing after the RSI simulation does not significantly improve student satisfaction. Self-Confidence Using the NLN Nursing Satisfaction and Self-Confidence in Learning instrument, selfconfidence scores showed statistical significance. The mean of the students who received debriefing was notably higher than the mean of the students who did not receive debriefing. This data supports the use of simulation debriefing to improve self-confidence in first year nurse anesthetist students. Knowledge Data analysis showed a twenty-five percent improvement of two test questions in the experimental group. Two questions had no change between the two groups and one question showed an eight percent increase in the experimental group. Even though statistically insignificant, these results indicate that knowledge scores did improve in students who received debriefing after the RSI simulation. An explanation for the two questions that remained unchanged between the groups is that the content was adequately covered in didactic. Therefore, simulation experience did not have an impact on the score of the two questions. Like various research studies, the RSI Simulation Project found simulation debriefing to be a key factor in simulation education. Most significantly, the use of the PEARLS debriefing tool improved student self-confidence scores when performing a rapid sequence induction using a high-fidelity mannequin. IMPROVING SIMULATION TRAINING 26 References Bajaj, K., Meguerdichian, M., Thoma, B., Huang, S., Eppich, W., & Cheng, A. (2018). The PEARLS healthcare debriefing tool. Academic Medicine: Journal of the Association of American Medical Colleges, 93(2), 336. https://doi.org/10.1097/ACM.0000000000002035 Berragan, L. (2014). Learning nursing through simulation: A case study approach towards an expansive model of learning. Nurse Education Today, 34, 1143-1148. Botma, Y. (2014). Nursing students perceptions on how immersive simulation promotes theory-practice integration. International Journal of Africa Nursing Sciences, 1,1-5. Doherty-Restrepo, J., Odai, M., Harris, M., Yam, T., Potteiger, K., & Montalvo, A. (2018). Students' perception of peer and faculty debriefing facilitators following simulation-based education. Journal of allied health, 47(2), 107112. Erlinger, L. R., Bartlett, A., & Perez, A. (2019). High-fidelity mannequin simulation versus virtual simulation for recognition of critical events by student registered nurse anesthetists. AANA journal, 87(2), 105109. Gebremedhn, E. G., Gebeyehu, K. D., Ayana, H. A., Oumer, K. E., & Ayalew, H. N. (2014). Techniques of rapid sequence induction and intubation at a university teaching hospital. World journal of emergency medicine, 5(2), 107111. https://doi.org/10.5847/wjem.j.issn.1920-8642.2014.02.005 Hayden, J.K., Smiley, R.A., Alexander, M., Kardong-Edgren, S., & Jeffries, P.R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5, supplement, s4-s64 IMPROVING SIMULATION TRAINING 27 Hegland, P. A., Aarlie, H., Strmme, H., & Jamtvedt, G. (2017). Simulation-based training for nurses: Systematic review and meta-analysis. Nurse education today, 54, 6 20. https://doi.org/10.1016/j.nedt.2017.04.004 Hustad, J., Johannesen, B., Fossum, M., & Hovland, O. J. (2019). Nursing students' transfer of learning outcomes from simulation-based training to clinical practice: a focusgroup study. BMC nursing, 18, 53. https://doi.org/10.1186/s12912-019-0376-5 INACSL International Association for Clinical Simulation and Learning. (2020). Simulation Design. https://www.inacsl.org/INACSL/assets/Image/simfographics/simulation-designhoriz.jpg INACSL Standards Committee (2016). INACSL standards of best practice: Simulation design. Clinical Simulation in Nursing, 12(S), S5-S12. http://dx.doi.org/10.1016/ j.ecns.2016.09.005 Kalaniti, K., & Campbell, D. M. (2015). Simulation-based medical education: Time for a pedagogical shift. Indian Pediatrics. 52(1), 41-45. https://doi.org/10.1007/s13312-015-05656 Keleekai, N. L., Schuster, C. A., Murray, C. L., King, M. A., Stahl, B. R., Labrozzi, L. J., Gallucci, S., LeClair, M. W., & Glover, K. R. (2016). Improving nurses' peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based blended learning program: A randomized trial. Simulation in healthcare: journal of the Society for Simulation in Healthcare, 11(6), 376384. https://doi.org/10.1097/SIH.0000000000000186 Lapkin, S., Fernandez, R., Levett-Jones, T., & Bellchambers, H. (2010). The IMPROVING SIMULATION TRAINING 28 effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: a systematic review. JBI library of systematic reviews, 8(16), 661694. https://doi.org/10.11124/01938924-20100816000001 Melnyk, B.M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins. Mollalign, M., Gebreegzi, A. H., Getinet, H., & Adem, S. (2019). Audit on current practice of rapid sequence induction and intubation of anesthesia in the university of gondar hospital, northwest Ethiopia. Anesthesiology Research and Practice. https://doi.org/10.1155/2019/6842092 Schwid, H. A., Rooke, G. A., Carline, J., Steadman, R. H., Murray, W. B., Olympio, M., Tarver, S., Steckner, K., Wetstone, S., & Anesthesia Simulator Research Consortium. (2002). Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study. Anesthesiology, 97(6), 14341444. https://doi.org/10.1097/00000542-200212000-00015 Shields, J. A., & Gentry, R. (2020). Effect of simulation training on cognitive performance using transesophageal echocardiography. American Association of Nurse Anesthetist. 88(1), 59-65. https://www.aana.com/docs/default-source/aana-journal-webdocuments-1/effect-of-simulation-training-on-cognitive-performance-usingtransesophageal-echocardiography-february-2020.pdf?sfvrsn=af8dd107_6 Shin, S., Park, J. H., & Kim, J. H. (2015). Effectiveness of patient simulation in nursing education: meta-analysis. Nurse education today, 35(1), 176182. https://doi.org/10.1016/j.nedt.2014.09.009 IMPROVING SIMULATION TRAINING Wiggins, L. L., Morrison, S., Lutz, C., & ODonnell, J. (2018). Using evidence-based best practices of simulation, checklists, deliberate practices, and debriefing to develop and improve a regional anesthesia training course. American Association of Nurse Anesthetist. 86(2), 119-126. https://www.aana.com/docs/default-source/aana-journalweb-documents-1/using-evidence-based-best-practices-of-simulation-checklistsdeliberate-practice-and-debriefing-to-develop-and-improve-a-regional-anesthesiatraining-course-april-2018.pdf?sfvrsn=c2505fb1_8 29 IMPROVING SIMULATION TRAINING 30 Appendix A Reference in APA format Level of Evidence Variables Literature Review Matrix Sample Instruments Berragan, L. (2014). Learning Level III-qualitative The impact of simulationThe upon participants learning forwere undergraduate A small-scale nursing narrative students. case nursing through simulation: A case descriptive study full time first year study. Semi-structured study approach towards an undergraduate interviews by telephone and via expansive model of learning. Nurse students (n = 9) e-mail. The interviews were Education Today, 34, 1143-1148. undertaking the RN tape recorded and transcribed BSc (Hons) Adult verbatim. Video recordings of Nursing programme, student simulation experiences. nurse educators (n = 3) who facilitated simulation sessions and registered nurse mentors (n = 4) who supported students in practice. Botma, Y. (2014). Nursing students Level III-qualitative Use of simulation with Convenient sampling. Standard evaluation form, audio perceptions on how immersive descriptive study high-fidelity maniquens n=33 tapes simulation promotes and standard simulation theory-practice integration. to assess theoryInternational Journal of Africa practice integration, Nursing Sciences, 1, 1-5. confidence, deliberate practice, motivation, and teamwork in third and fourth year nursing students Doherty-Restrepo, J., Odai, M., Level III Harris, M., Yam, T., Potteiger, K., & Montalvo, A. (2018). Students' perception of peer and faculty debriefing facilitators following simulation-based education. Journal of allied health, 47(2), 107112. Erlinger, L. R., Bartlett, A., & Level III Perez, A. (2019). High-fidelity mannequin simulation versus virtual simulation for recognition of critical events by student registered nurse anesthetists. AANA journal, 87(2), 105109. Hayden, J.K., Smiley, R.A., Alexander, M., Kardong-Edgren, S., & Jeffries, P.R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5, supplement, s4-s64 Level II-National study, longitudinal, randomized, controlled trial dependent variables: Convenient sampling. 1) students' selfn=33 reported confidence in performing an orthopedic assessment of the knee on a simulated patient, and 2) students' assessment of the effectiveness of the debriefing A total sample of n=39 39 students agreed to participate and were randomly assigned into 2 groups. One group participated in a virtual simulation first, followed by a highfidelity mannequin simulation. The other group participated in a highfidelity mannequin simulation first, followed by a virtual simulation. Use of simulation to determine if simulation was an appropriate substitute for clinical experience. Control group: Traditional clinical experience with no more than 10% simulation. 25% group replaced by sim. 50% group replaced by simulation. n=10 (Schools of Nursing): 5 ADN, 5 BSN, geographically diverse, community colleges and large universities. 3 groups used, sample of 200 students per group. 847 students consented to study. 666 completed the study. Results Data analysis through progressive focusing revealed that the nurse educators viewed simulation as a means of helping students to learn to be nurses, whilst, the nurse mentors suggested that simulation helped them to determine nursing potential. The students' narratives showed that they approached simulation learning in different ways resulting in a range of outcomes: those who were successfully becoming nurses, those who were struggling or working hard to become nurses and those who were not becoming nurses. Simulation promotes theorypractice integration, builds confidence, makes students aware of the aspects of care that need to be improved through deliberate practice, increases the motivation to learn and transfer their knowledge, and strengthens communication among team members. Knowledge on the benefits of simulation can guide nurse educators to harness the method to enhance transfer of learning. Debriefing Assessment for Simulation-based education is recognized as an effective Simulation in Healthcare. SPSS method to promote confidence and improve clinical skills version 17.0. n=23 in students by providing constructive feedback through debriefing. Nonparametric tests were performed for the data analysis. Mann-Whitney U statistical tests were performed and Wilcoxon rank sum test. Creighton Competency Evaluation Instrument, Clinical Learning Environment Comparison Survery, Critical Thinking Diagnostic, Ner Graduate Nurse Performance Survery, knowledge assessed by ATI RN Comprehensive Predictor 2010, Global Assessment of Clinical Competency and Readiness for Practice, National Council Licensure Examination. Hegland, P. A., Aarlie, H., Level I-Systematic The aim of this 58 articles were Two authors screened all titles Strmme, H., & Jamtvedt, G. review and meta- systematic review is to selected after and abstracts independently. (2017). Simulation-based analysis evaluate effect of screening for full-text Data was retrieved by one training for nurses: Systematic simulation-based review. 15 RCTs person and quality checked by review and meta-analysis. Nurse training on registered were used. Inclusion the other. education today, 54, 620. nurses' skills and criteria were RCT https://doi.org/10.1016/j.nedt.2017. knowledge. evaluating the effect 04.004 of simulation-based raining for graduate nurses or graduated nurses in continuing education. The findings from this study indicate that among secondyear SRNAs, the use of high-fidelity mannequin simulation led to quicker recognition of intraoperative MI. However, among third-year SRNAs in our study, there was no difference between both simulation methods in the time it took to recognize an intraoperative MI. Up to 50% simulation can be effectively substituted for traditional clinical experience in nursing students. Highquality simulation must be provided with best practices. Simulation can euqally prepare students for the NCLEX and allow for adequate knowledge and clinical competence when compared to traditional clinical. Findings show simulation training appears to be an effective strategy to improve nurses' skills, but further goodquality RCTs with adequate sample sizes are needed. IMPROVING SIMULATION TRAINING Hustad, J., Johannesen, B., Fossum, M., & Hovland, O. J. (2019). Nursing students' transfer of learning outcomes from simulation-based training to clinical practice: a focus-group study. BMC nursing, 18, 53. https://doi.org/10.1186/s12912-0190376-5 Keleekai, N. L., Schuster, C. A., Murray, C. L., King, M. A., Stahl, B. R., Labrozzi, L. J., Gallucci, S., LeClair, M. W., & Glover, K. R. (2016). Improving nurses' peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based blended learning program: A randomized trial. simulation in healthcare : journal of the Society for Simulation in Healthcare , 11(6), 376384. https://doi.org/10.1097/SIH.000000 0000000186 Level IIIQualitative descriptive design 31 A qualitative n=32 (second or third descriptive design with year nursing students) focus group interviews was adopted focus group interviews. The demographic data were analysed using descriptive statistics The results showed that simulation-based training promoted self-confidence as well as improved clinical skills and judgement, and the participants discovered the importance of communication and team collaboration in a clinical context. n=59. The study was a n=63 (group A n=30, randomized, wait-list group B n=33) control group with crossover using nurses on three medical/surgical units. Baseline PIVC knowledge, confidence, and skills assessments were completed for both groups. The intervention group then received a 2-hour PIVC online course, followed by an 8-hour live training course using a synergistic mix of three simulation tools. Both groups were then reassessed. After crossover, the wait-list group received the same intervention and both groups were Lapkin, S., Fernandez, R., LevettLevel I-Systematic Included undergraduate 21 publications were Jones, T., & Bellchambers, H. Review of all nursing students and the used for review and 8 (2010). The randomized and use of high-fidelity were included in the effectiveness of using human patient quasi-randomized simulation mannequins. review. simulation manikins in the teaching controlled trials The study measured of clinical reasoning skills to critical thinking, undergraduate nursing students: a clinical skill systematic review. JBI library of performance, systematic reviews, 8(16), 661694. knowledge, confidence, https://doi.org/10.11124/01938924and student satisfaction 201008160-00001 with simulation experience. Demographic data form, peripheral intravenous catheter insertion knowledge assessment, The current randomized control trial was conducted to evaluate the impact of a simulation-based blended learning program on nurses' PIVC insertion knowledge, confidence, and skills. Results demonstrate significant improvements in nurses knowledge, confidence, and skills with the use of a simulation-based blended learning program for PIVC insertion. Transferability of these findings from a simulated environment into clinical practice should be further explored. Systematic review of research articles The use of human patient simulation mannequins improves three outcomes integral to clinical reasoning: knowledge, critical thinking, and the ability to identify deteriorating patients. Students reported high levels of learner satisfaction. Mollalign, M., Gebreegzi, A. H., Level IIGetinet, H., & Adem, S. (2019). Obersvational Audit on current practice of Study rapid sequence induction and intubation of anesthesia in the university of gondar hospital, northwest Ethiopia. Anesthesiology Research and Practice. https://doi.org/10.1155/2019/68420 92 All elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation during the audit period. Data were collected by using a standard checklist. &e checklist was primarily prepared in English language. After completion of data collection, the data were entered in Microsoft Excel for analysis. Guidelines used as reference for this clinical audit were World Federation of Societies of Anesthesiologists, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, British Journal of Anesthesia, National Institute of Health, and World Journal of Emergency Medicine Most anesthetists were good at preparing all available monitoring and drugs, making sure that IV line is well-functioning, preparing suction with a suction machine, preoxygenation, application of cricoid pressure, and checking the position of the ETT after intubation was performed. Preparing difficult airway equipment during planning of rapid sequence induction and intubation, giving roles and told to proceed their assigned role for the team, attempt to ventilate with a small tidal volume, and routine use of bougie or stylet to increase the chance of success of intubation needed improvement. Schwid, H. A., Rooke, G. A., Level II Carline, J., Steadman, R. H., Murray, W. B., Olympio, M., Tarver, S., Steckner, K., Wetstone, S., & Anesthesia Simulator Research Consortium. (2002). Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study. Anesthesiology, 97(6), 14341444. https://doi.org/10.1097/00000542200212000-00015 Anesthesiology n=99 departments at 10 institutions with METI (Medical Education Technologies Inc., Sarasota, FL) or MedSim (MedSim Inc., formerly of Ft. Lauderdale, FL) mannequin-based simulators participated in this study. The simulation scenarios and grading forms used in this study were developed and used in a prior study involving over 30 simulator sessions. 3The scenarios and grading forms were circulated to the 32 anesthesiologists who contributed to this study for comments and suggestions. The simulation sessions were videotaped using two camera angles to capture the subject's clinical management and the anesthesia machine and monitors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes. Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores Level I- RCT A total of 35 patients were operated during the study period. Of these, 31 (88.57%) patients were adults and 4 (11.43%) patients were pediatrics. Most of the patients were emergency (29 (82.857%)), and the rest were elective (6 (17.142%). IMPROVING SIMULATION TRAINING 32 Shields, J. A., & Gentry, R. (2020). Level III Effect of simulation training on cognitive performance using transesophageal echocardiography. American Association of Nurse Anesthetist. 88(1), 59-65. https://www.aana.com/docs/defaultsource/aana-journal-web-documents1/effect-of-simulation-training-oncognitive-performance-usingtransesophageal-echocardiographyfebruary2020.pdf?sfvrsn=af8dd107_6 Dependent Variable: n=71 (SRNAs) Measure on pretests/posttest exam scores Groups: QuasiIndependent Variables: students who receive web-based education over 1 week and studetns who received in person simulation for 2 hrs Video based (ExamSoft) assessment tool One group underwent web-based simulation training and one group underwent in person simulation training. Both groups showed improvement, but the SRNAs who underwent simluation training in person scored higher on posttest evaluations. Shin, S., Park, J. H., & Kim, J. H. Level I-Meta (2015). Effectiveness of patient analysis simulation in nursing education: meta-analysis. Nurse education today, 35(1), 176182. https://doi.org/10.1016/j.nedt.2014. 09.009 The effects of patient n=20 artciles simulation in nursing education in various learning environments and the use of different evaluation techniques. meta-analysis Simulation-based learning did increase scores on knowledge and skill examinations. Results give evidence for the effectiveness of simulation education, which provides students with authentic clinical situations and allows them to practice nursing skills in safe environments. Wiggins, L. L., Morrison, S., Lutz, Level IIII C., & ODonnell, J. (2018). Using evidence-based best practices of simulation, checklists, deliberate practices, and debriefing to develop and improve a regional anesthesia training course. American Association of Nurse Anesthetist. 86 (2), 119-126. https://www.aana.com/docs/defaultsource/aana-journal-web-documents1/using-evidence-based-bestpractices-of-simulation-checklistsdeliberate-practice-and-debriefingto-develop-and-improve-a-regionalanesthesia-training-course-april2018.pdf?sfvrsn=c2505fb1_8 Measurement: n=49 (CRNAs) Dependent Variable (Precourse/Postcourse comfort and confidence levels). Group: QuasiIndependent Variables (4 hour online course and Hands on practice). Precourse demographic survey The confidence and comfort level for epidural and spinal and atttitude survey, skills blocks were higher when compared to results from prior to assessment/ checklist, simulation training. postcourse survey IMPROVING SIMULATION TRAINING 33 Appendix B PEARLS Debriefing Framework, by Eppich & Cheng, 2015, Journal of the Society for Simulation in Healthcare, 10(2), 106115(https://doi.org/10.1097/SIH.0000000000000072). Copyright 2015 by Wolters Kluwer Health, Inc. Reprinted with permission. IMPROVING SIMULATION TRAINING 34 Appendix C PEARLS Debriefing Script, by Eppich & Cheng, 2015, Journal of the Society for Simulation in Healthcare, 10(2), 106115(https://doi.org/10.1097/SIH.0000000000000072). Copyright 2015 by Wolters Kluwer Health, Inc. Reprinted with permission. !"#$%&!'()*!"+,-.!%').$-!'!'( 02 A<<)%=$N&7 i*:7<=5:)*9:4GD9?:425)95<)*=8DZE25D4<=5?=)45),=915456)X7=G:4255941=Kj)CH)'9:42598),=967=)D21) '71G456K)NOO^)TA::0;kk@@@I585I216k<2?Gk<=D978:ZG271?=k<=D978:Z<2?7/=5:Z84C191Hk45G:17/=5:Z NLG9:4GD9?:425Z95

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... The North Meridian Review Fall 2021 Volume 2 Issue 1 A Journal of Culture and Scholarship EDITORIAL STAFF Managing Editor: Wesley R. Bishop, Marian University Indianapolis Assistant Managing Editor: Mauve Perle Tahat, Indiana University of Pennsylvania Assistant Editor: Robin Marie Averbeck, California State University, Chico Assistant Editor: Janine Giordano Drake, Indiana University Bloomington Assistant Editor: Paula Ashe, Purdue University Assistant Editor: Lama Sharif, Purdue University Book Review Editor: Alzbeta Hajkova, Purdue University Poetry Editor: Ricardo Quintana Vallejo, Universidad Nacional Autnoma de Mxico Digital Editor: Pdraig Lawlor, Canterbury Preparatory School, CT EDITORIAL BOARD Andrea Adomako, Northwestern University Andy Older, Embry-Riddle Aeronautical University Saladin Ambar, Rutgers University Patricia Oman, Hastings College Nebraska Malkah Bird, Jewish Voices for Peace Claire Perrott, Marian University Indianapolis Rachel Brown, Marian University Indianapolis Bessie Rigakos, Marian University Indianapolis Michelle Campbell, University of Michigan Richard Schneirov, Indiana State University Valentina Concu, Universidad del Norte Carina Shero, Chicago activist and artist LaShawnda Crowe Storm, IUPUI-The Polis Center Harry Targ, Professor Emeritus-Purdue University John Enyeart, Bucknell University Ashley J. Velzquez, University of Washington, Bothell Adrianna Ernstberger, Marian University Indianapolis Naomi R Williams, Rutgers University Nancy Gabin, Purdue University Victoria Saker Woeste, Independent Scholar Iridessence, Chicago activist and artist Ruisheng Zhang, Tsinghua University Preethi Krishnan, Western Carolina University Michelle Moyd, Indiana University Bloomington 2 Table of Contents I. SCHOLARSHIP Adeyemi Doss.10 II. PROSE Valentina Concu, Wesley Bishop......36 Peter Cole....64 Daniel Lockhart...82 Marcia Eppich-Harris... ...91 Luanne Castle..104 Daniel Morris..114 Wm. Anthony Connolly..... 118 Michelle Moyd....127 III. POETRY Ricardo Quintana Vallejo, Introduction....134 Tina Schumann.....136 Mariana Mcdonald140 Patricia Thrushart.144 DS Maolalai..........146 Xiaoly Li.......149 Steven Luria Ablon.......151 Elizabeth Weir.152 Kari Wergeland153 Kat Bodrie............156 Ellen Sazzman..........159 Kate Pashby161 Mike Wilson............163 John Grey............164 Gerard Sarnat..169 David Estringel........172 Lisa Bullard........174 Connemara Wadsworth.......180 V. BOOK REVIEWS Jess Montgomery. The Stills. Reviewed by Betty J. Bruther.......183 Grays, Donnetta Lavinia. Where We Stand. Directed by Dwandra Kickole Lampkin, Summit Theatre Performance, May 22, 2021. Reviewed by Ben Tebbe..187 Gannis, Scott. Very Fine People. Reviewed by Doug Sheldon....190 Susan Abulhawa. Against the Loveless World: A Novel. Reviewed by Fouad Mami..193 Clint Jones. Stranger, Creature, Thing, Other: Monstruous Reflections on Our Ecostential Crisis. Reviewed by John William Nelson.........196 James H. Madison. The Ku Klux Klan in the Heartland. Reviewed by John Lepley.......199 Nicholas Newman. The Political Works of Remigius Dei Girolami. Reviewed by Samuel C. C. Bunch...202 Thomas Sanfilip. Conversations with Mona Lisa. Reviewed by Jennifer J. Smith...205 3 4 Introduction: A Time of Reflective Survival Wesley R. Bishop Another year has passed, and here we are again with the fall issue of The North Meridian Review. Academic publishing is incredibly slow, moving at a pace that makes a snail seem like a sprinter. For those unfamiliar with this glacial process, it can seem annoying and unnecessarily cumbersome, but personally I have always found it somewhat refreshing. As part of a generation of writers that grew up with the internet, a sphere of text with a speed limit around the velocity of light, it is comforting to know that in some venues projects are measured in months, years, and sometimes even longer. Yet that feature, which means academic writers and editors must choose their words carefully to avoid being obsolete before going to print, makes commenting on the immediacy of a rapidly changing world somewhat difficult. 2020 and 2021 have certainly been those types of hyperactive years. A global pandemic, massive protests, an attempted insurrection in the American capitol, and the tumultuous final year of Donald Trumps presidency were events almost custom-tailored for tweets, hashtags, and minute-by-minute updates. Therefore, as the pieces of this current issue formed and rolled in over the course of a year, we at NMR were not surprised to see an emerging theme reflective survival. I write this introduction from the campus of Marian University Indianapolis, a quiet corner of an unassuming Midwest city, but this year has shown that despite illusions of separation and isolation we are interconnected in profound ways. Millions have now died from the pandemic, and new variants still pose untold risks to our communities. Likewise, for much of the rest of the world the crisis has not even been alleviated due to hoarding of vaccines. And so, we have a situation where the bigotry of borders rears its ugly head yet again, hoarding vaccines for certain people, denying it to others. For those of us who have survived this first wave of pandemic, we reflect on what our survival means. What world is emerging from these multiple crises? What world do we fear, what world do we dream of, and where can we find ourselves in that negotiated in-between? Our peer-reviewed scholarly article by Indiana State University professor Adeyemi Doss explores this by asking us to question the divide of public and private conceptions of Blackness. Daniel Lockhart and Michelle Moyd, in our prose section, deal specifically with the themes of isolation, ruin, and persistence in an age of disease. Ricardo 5 Quintana Vallejo, our new poetry editor, put out an excellent call for poems discussing the pandemic. Numerous poets from around the world responded with a host of viewpoints. That said, the fall issue of NMR is never dedicated to a single issue. Valentina Concu and I finish a two-part series translating and discussing testimonies from the Italian Holocaust, and Marcia Eppich-Harris, Luanne Castle, Daniel Morris, and Wm. Anthony Connolly write on topics ranging from memoir to the threat of political tyranny. We conclude, as always, with a book review section examining new titles in the various fields of the humanities. This journal originated out of the collective vision of a group of Indiana-based thinkers, writers, and artists, and was originally thought to be housed in the Department of History and Social Sciences at Marian University. Yet, as stated above, the world often moves faster than academic publishing, and in the summer of 2021 it was decided that the department would no longer exist, being split into two separate schools. What this means for the future of the journal remains to be seen. This journals central mission has been, and will continue to be, a space for reflection both in times of survival and prosperity. As long as we continue to publish, we will remain a humanities journal for humanity, a humane space in the face of inhumane forces. Where we go from here as a publication, a city, a country, and a global civilization is not yet written, but no matter where we go next the practice of surviving, reflecting, surviving again, and reflecting more will always be needed for us, the residents of the North Meridianfrom the Circle City to around the globe. Dear reader, it is a pleasure and privilege to bring you this years fall edition of The North Meridian Review: A Journal of Culture and Scholarship. Wesley R. Bishop Managing and Founding Editor The North Meridian Review Indianapolis, Indiana Fall 2021 6 Biographies Dr. Adeyemi Doss is an Assistant Professor in the Department of Multidisciplinary Studies, where he teaches various classes in sociology. He holds an M.A. and a Ph.D. in African American and African Diasporic Studies with a minor in Philosophy from Indiana University, Bloomington. As a scholar, Dr. Doss' research interests are shaped by a growing trend towards producing scholarships that address issues facing African American men and boys. His research raises important questions about black subjectivity, patterns of black spatial mobility, and embodied resistance. Luanne Castle's Kin Types (Finishing Line Press), a chapbook of poetry and flash nonfiction based on family and regional history, was a finalist for the 2018 Eric Hoffer Award. Her first collection of poetry, Doll God, winner of the 2015 New Mexico-Arizona Book Award, was published by Aldrich Press. Luanne has been a Fellow at the Center for Ideas and Society at the University of California, Riverside. She studied English (specialties in American literature, history, theory, and poetry) at the University of California, Riverside (PhD); Creative Writing, English, and History at Western Michigan University (MFA); and Creative Writing at Stanford University (certificate). Her Pushcart and Best of the Net-nominated poetry and prose have appeared in Copper Nickel, American Journal of Poetry, Pleiades, River Teeth, TAB, Verse Daily, Lunch Ticket, Glass: A Journal of Poetry, Broad Street, Studies in American Jewish Literature, The Review Review, and other journals, as well as many anthologies and craft texts. Luanne blogs about writing, cats, and everyday life at writersite.org and about genealogy at thefamilykalamazoo.com. She can also be found at luannecastle.com. Luanne divides her time between California and Arizona, where she shares land with a bobcat and other wildlife. Peter Cole is a professor history at Western Illinois University in Macomb and a research associate in the Society, Work, and Development Institute at the University of the Witwatersrand in Johannesburg, South Africa. Cole is the author of the award-winning Dockworker Power: Race and Activism in Durban and the San Francisco Bay Area (University of Illinois Press, 2018) and Wobblies on the Waterfront: Interracial Unionism in Progressive-Era Philadelphia (University of Illinois Press, 2007). He edited Ben Fletcher: Life and Times of a Black Wobbly, 2nd ed. (PM Press, 2021) and coedited Wobblies of the World: A Global History of the IWW (PM Press, 2017). He is the founder and codirector of the Chicago Race Riot of 1919 Commemoration Project. Valentina Concu is an Assistant Professor of Linguistics and Head of the German Department at the Institute of Foreign Languages at the Universidad del Norte, in Barranquilla, Colombia. She did her undergraduate studies in foreign language at the University of Cagliari (Italy) and the Universitt Potsdam (Germany). She received her first M.A. in German and Spanish also from the University of Cagliari and lived in Germany for 7 years where she taught Italian in public and private schools. In Fall 2013, she started her graduate studies at Purdue University, (USA). In July 2015, she got her second M.A. in German and started her Ph.D. in Linguistics right after. She received her Doctoral Degree in February 2021. Her research interests focus on but are not limited to historical corpus linguistics, historical pragmatics, complexity theory, complex network science, second language acquisition, and cultural studies. Wm. Anthony Connolly is a writer and librarian living on the Delmarva Peninsula with his wife Dyan and their two dogs, Hemingway Short Story and Professor Leo Tolstoy. 7 Marcia Eppich-Harris holds a PhD in Shakespeare and Dramatic Literature and taught at the college level for roughly fifteen years. She is a playwright and a founding member of the Indiana Playwrights Circle (IPC), where she is the Scene Nights Coordinator and serves on the steering committee. Marcias writing includes plays, fiction, poetry, scholarship, and reviews. Her creative writing is influenced by the literature and history of the ancient Greeks and Romans, the British Medieval and Renaissance periods, as well as current events. She focuses thematically on politics, philosophy, the arts, gender, family, and culture. Marcia is also the artistic director of Southbank Theatre Company, in Indianapolis. D.A. Lockhart is the author of Breaking Right (Porcupine's Quill, 2021) and Bearmen Descend Upon Gimli (Frontenac House, 2021). His work has appeared in Best Canadian Poetry in English 2019, New Poetry from the Midwest, TriQuarterly, ARC Poetry Magazine, Grain, Belt, and the Malahat Review among many others. He is a Turtle Clan member of Eelnaapewi Lahkewiit (Lenape), a registered member of the Moravian of the Thames First Nation, and currently resides at the south shore of Waawiiyaatanong (Windsor,ON-Detroit, MI) and Pelee Island. He is the publisher at Urban Farmhouse Press and the Poetry Editor at the Windsor Review. Daniel Morris is a Professor of English at Purdue. His latest book of poems is Blue Poles with Marsh Hawk Press. Michelle Moyd is Ruth N. Halls Associate Professor of History at Indiana University, Bloomington, where she is also the Associate Director of the Center for Research on Race and Ethnicity in Society (CRRES). She is the author of Violent Intermediaries: African Soldiers, Conquest, and Everyday Colonialism in German East Africa (Ohio University Press, 2014) and co-author, with Yuliya Komska and David J. Gramling, of Linguistic Disobedience: Restoring Power to Civic Language (Palgrave, 2018). 8 I. SCHOLARSHIP 9 The Burden of Public Blackness and the Promise of Black Privacy Adeyemi Doss Abstract This essay explores the impact of being Black in private (i.e., black privacy) to shield the black body from the taxing nature of being black in public (i.e. public blackness). Deriving from the tragic deaths of Breonna Taylor, George Floyd, and Ahmad Arbery, I offer an existential description of how the black body is perceived in public blackness, and the direction black privacy must follow for black people to sustain a sense of self. This essay also connects public blackness to a long-standing societal practice of restricting the movement of black peoples bodies, which arises from anti-black ideologies that see the black body as a problem rather than a human being. Introduction: Horrendous images of lifeless black bodies flash through my mind like a nightmare, preceded by a constant stream of screams and cries of protest. On May 7, 2020, I watched the first viral video of twenty-five-year-old Ahmad Arbery being chased and killed by three white men while jogging near his home. I felt a wave of dread and anxiety wash over me while at the same time wishing he could flee the ferocious appetite of his killers. On May 25, 2020, Derek Chauvin, a Minneapolis police officer, was caught on camera pinning George Floyd to the pavement for 9 minutes and 29 seconds with a knee to his throat, causing Mr. Floyd to die due to lack of oxygen to the brain. I was sitting on my couch the day Floyd was murdered, watching him take his last breath while he cried out for his mother, wishing he was able to sink into the asphalt and then resurface when it was safe for him to be visible again. As part of a drug trafficking investigation, Jonathan Mattingly, Brett Hankison, and Myles Cosgrove of the Louisville Metro Police Department forced their way into Breonna Taylors home on 10 March 13, 2020, killing her as she slept in her bed. I could not help but wonder what would happen if Breonna was able to fade into the night, only to return when it was safe to do so. For months I have watched their dead bodies be recycled in the media, become focal points of mass demonstrations, and serve as a stark reminder to any black person in America of their social status as bodies placed outside of the world of moral concern. 1 In light of the tragic deaths of Arbery, Floyd, Taylor, and countless others, I am forced to question my life as a black father, husband, son, and scholar living in a predominantly white community with a history of anti-Black violence, while asking the seemingly impossible questions: What if the black body could be liberated from a society that considers it as something to be policed, despised, distorted, and erased? What happens when the black body is no longer reduced to the level of the flesh and can break free from being stuck in an ontological space I refer to as public blackness, where it exists only as a feared object? What does a black body have to go through to be recognized and accepted as a human being? I ask these questions in private while I try to come to terms with the fear and anxiety evoked by depictions of black peoples pain and death. In a state of isolation (i.e., black privacy), I can envision a world where the body I see and breathe from is no longer a danger or threat to society but rather a body free to coexist peacefully with other bodies. As a response, these barriers refer to the paradox of the black body living in two worlds, which occurs when black people find themselves roaming across white social spaces, the white imagination, and the visual field of the white gaze, all of which have been conditioned to see black bodies as a problem (the terms white gaze and white imagination will be used interchangeably with cultural gaze and gaze of white supremacy within the body of this essay). David William Hart, Dead Black Man, Just Walking, in Pursuing Trayvon Martin: Historical Context and Contemporary Manifestations of Radical Dynamics, ed. George Yancy and Janine Jones (Lanham, Md.: Rowman & Littlefield Publishing, 2013), 18. 1 11 Being a black man in America has meant fighting a seemingly endless battle against a society that only sees one as a criminal. I began to find emotional relief in the concept of black privacy as a means of avoiding the thought of my mortality. I find myself drawn to places where I am isolated in my attempt to cope with the deaths of Arbery, Floyd, and Taylor, the infectious wrath of COVID-19, as well as the troubling reality that being black in an anti-Black society means continuously facing violence and physical death, as well as a social death that becomes increasingly interwoven with ones life experience. Therefore, black privacy becomes a way of survival and a way of life. What is Black Privacy? Before I go any further, I would like to explain how I use the concepts of black privacy and public blackness in my work. Black privacy is, first and foremost, a means of mental defiance against American societys concerted disregard for black peoples humanity. This, I contend, derives from a collective perspective and imagination socially conditioned to see and imagine the black body as a threatening object. As a result, black privacy for black people becomes an intrapsychic battle that can be interpreted as the bodys attempt to avoid becoming psychologically or physically victimized and as a desire to avoid being treated as a problem rather than a human being. Within the notion of black privacy, the fear of being perceived as a problem drives some black people to question their existence in a specific space or in society. This phenomenon can cause some black people to question what it means to be publicly visible as a racial body and raise concerns about societys failure to recognize black peoples humanity. When we bring into question race relations in the United Sates, according to George Yancy in his 2008 book Black Bodies, White Gaze: The Continuing Significance of Race, many whites have been socialized to see the Black body through the medium of 12 historically organized types of information that treat it as an object of suspicion. 2 Black people and their bodies, become a prisoner of an imagean elaborate distorted image of the Black, an image whose reality is held together through white bad faith and projection that is ideologically orchestrated to leave no trace of its social and historical construction. 3 For decades, black people have had to battle and proactively create themselves to survive the burdensome nature of anti-Black violence, oppression, and hypervisibility, along with Americas methods of policing black peoples bodies. 4 The concept of black privacy in reference to my reflection of my existence in a society where being seen as a problem becomes a reality in that I must frequently struggle against the domination of a cultural gaze; my ultimate fight becomes a fight to live. I will go into greater detail about Americas carceral effect by first looking at the historical context of lynching as a way of policing the bodies of black men and boys and its relationship to current issues of black masculine body confinement. What is Public Blackness? The complex nature of public blackness operates as an ontological sphere when the black body is present. In public blackness, black people and their bodies encounter a cultural gaze and imagination that it seeks to suppress as it moves about in a specific space or in society. Black people are confronted and more so haunted with the fear of being stereotyped in public. External features of blackness and black bodies (such as flesh, hair texture and color, body size, and eye color) are often stereotyped, influencing peoples racial experience(s). According to Michael Omi and Howard Winant in Racial Formation in the United States from the 1960s to the 1990s, One of the first things we notice about people when we meet them (along with sex) is their race. We utilize race to provide clues about who a person is. This fact is made George Yancy, Black Bodies White Gaze: The Continuing Significance of Race (Lanham, Md.: Rowman & Littlefield Publishing, 2008), 3. 3 Ibid., 110. 4 Ibid., 117 2 13 painfully obvious when we encounter someone whom we cannot conveniently racially categorizesomeone who is, for example, racially mixed or of an ethnic/racial group we are not familiar with. Such an encounter becomes a source of discomfort and momentarily a crisis of racial meaning. 5 In public blackness, I argue that black peoples racial experience is not so much a fleeting crisis of racial meaning as it is, for some, a permanent component of the way they experience life as a racial body. Our ability to interpret racial meanings depends on preconceived notions of a racialized social structure, Omi and Winant go on to claim. Comments such as Funny, you dont look black betray an underlying image of what black should be. We expect people to act out their apparent racial identities; indeed, we become disoriented when they do not. 6 The way the black body and blackness are seen and imagined is directly linked to the flawed idea(s) of what and how black people are and should act. Thus, blackness becomes the pit of human life under the ideology of anti-blackness, the racial sense of what it means to be black in a racialized society where race is used as a social marker. As a result, blackness is also seen as the underside of humanism, the consequence of humanism in which those who appear to exist in blackness can be alienated, and exiled at any time. 7 To comprehend the impact of public blackness on the lives of black people, we must first consider how the collective gaze views blackness and the consequences of being caught in the gaze. In public blackness, the black body is trapped in the visual cortex of a cultural gaze that has been conditioned to see it as something other than human. It is worth noting that the gazes visual field is the ontological anatomy of public blackness. Therefore, public blackness strongly relies on the gaze to regulate the movement of black people. It is not just the look (i.e., gaze) that causes problems for the Black body engrossed in its visual field while in public; it is also what is behind the look that Michael Omi and Howard Winant, Racial Formation in the United States from the 1960s to the 1990s (New York: Routledge, 1994), 59. 6 Ibid. 7 William David Hart, Constellations: Capitalism, AntiBlackness, Afro-Pessimism, and Black Optimism, American Journal of Theology & Philosophy 39, no. 1 (2018): 20. 5 14 causes problems for the Black body engrossed in its visual field (i.e., the imagination). What then is the connection between the Black body, the white gaze, and imagination? In an anti-Black society, how are Black peoples bodies conceptualized? The Black Body as a Problem When youre young and youre Black, no matter how you look you fit the description. You fit the description of the nonbeing, the being out of place, and the noncitizen always available to and for death. 8 -Christina Sharpe When considering the problem of the Black body, we must interrogate the questions posed by two critics. W. E. B. Du Bois raises the question of the phenomenology of Black experience by asking, How does it feel to be a problem? 9 Ronald L. Jackson III asks about the cultural production of this experience of marginalization, inquiring, How did Black bodies become a problem in the first place? 10 According to Jackson, the social assignment of Black bodies to an underclass is a historical conundrum that has multiple origins, two of which are the institutions of slavery and the mass media. 11 Throughout the historical development of Black body politics, Black bodies were inscribed with a set of meanings, which help perpetuate the scripters racial ideology. 12 Those meanings have remained to disturb every phase of Black life in America. The system of white supremacy inscribes a set of meanings onto Black peoples corporeality that impedes their spatial mobility in society. The scripting of the Black body and Black body politics have often unveiled the embedded racially xenophobic tendencies that are redistributed and recycled in mass-media cultural Christina Sharp. In the Wake: On Blackness and Being (Durham: Duke University Press, 2016), 86. W. E. B. Du Bois, The Souls of Black Folk: 100th Anniversary Edition (Boulder: Paradigm Publisher, 2004), 1. 10 Ronald L. Jackson II, Scripting the Black Masculine Body: Identity, Discourse, and Racial Politics in Popular Media (Albany: State University of New York Press, 2006), 9. 11 Ibid., 9. 12 Ibid., 9. 8 9 15 practices. 13 The Black body steadily struggles not to capitulate to the mental and physical stress produced by these public Blackness practices that construct it as a problem. David Polizzi reminds us in his Social Presence, Visibility, and the Eye of the Beholder: A Phenomenology of Social Embodiment, reflecting on the killing of Trayvon Martin, that the Black body continues to be constructed as the manifestation of social threat and danger. As such, the contours of these constructed fears are not only present within the visibility of the physical body, but also come to represent a type of geographical demarcation or territorialization whereby the Black body may be legitimately presenced as a problematic bodyTrayvon Martins killing represents not only the way in which his killer constructed the meaning of his presence, but the way in which the social context of that presencing was employed by him to further justify the legitimacy of this construction. 14 The concept of public Blackness is extremely complex when considering how the Black body is constructed in public as a problem. In the battle against this racialized paradigm that portrays the Black body as a problem often used to justify its abuse, the significance of Black privacy offers a type of ontological space where Black people can reinvent themselves. In the reinvention of self, Black privacy transforms into a survival mechanism, driving the body and the mind to disengage from the perception of being perceived as a problem. In a racialized society, Black people have had to fight and constantly create themselves to survive. 15 Black people live in a world that is warped with distortions of their reality. For some Black people, experiencing public Blackness is akin to experiencing a kind of social death, where one becomes vulnerable in losing sight of ones own identity. It is also the psychological experience of confronting the possibility of dying. This is due to the same misconceptions that have helped create the Black body as a problem and, consequently, have contributed to its degradation and continued abuse. Ibid., 9. David Polizzi, Social Presence, Visibility, and the Eye of the Beholder: A Phenomenology of Social Embodiment (Lanham, Md.: Rowman & Littlefield Publishing, 2013), 174. 15 Yancy, Black Bodies White Gaze, 117. 13 14 16 In contemporary America, Black males, for example, are both seen and imagined as inherently violent, irresponsible, and angry street urchins. 16 Unlike his counterpart [ the white male], his body is often scripted as a young, innocent, and immature individual. 17 Thus, for Black men and boys the probability of facing violence is a part of everyday existence. As Tommy Curry argues, The demonization, social marginalization, and extermination of Black males, specifically heterosexual Black males, is among the most long-standing practice of white Americas patriarchal regime. 18 Conversely, this long-standing practice has a profound impact on the lives of Black men and boys, leading some to turn inward to cope with the mental and physical anxiety and fatigue imposed by public Blackness. When I consider my own experience as a Black man traveling in spaces occupied by my white peers, I become more mindful of my body schema. I am fighting the urge not to fit into the scripters prose as something to be feared now that I am conscious of the possibilities that lie ahead. Now that I have seen what being feared can do to the Black body when it is engulfed in public Blackness, I am wary about being trapped inside the visual field of the cultural gaze. Consequently, countless people who resemble me have died. To avoid death, both physically and mentally, is to avoid societys distortions of my body as well as the control that whiteness tries to maintain through my death. I seek ways to escape public Blackness (i.e., being Black in public) by practicing Black privacy in my way of physically moving about in the world. My thoughts are largely focused on how my body, like the bodies of other Black men and boys, evokes fear in white America. The fear that my body is encased in becomes so intense that I Jackson, Scripting the Black Masculine Body, 82. Ibid. 18 Tommy J. Curry, Killing Boogeymen: Phallicism and the Misandric Mischaracterizations of Black Males in Theory, Res Philosophica 95, no. 2 (2018): 247. https://www.doi.org/10.11612/resphil.1612. 16 17 17 seriously wonder if the problem is with my body or the outer tones of my skin. As a response, I am forced to consider both my skin color and the meaning of Blackness in a racially divided society, where both are fundamental to Americas values, morality, and expectations that people of African descent are intrinsically inferior and irredeemable. For those reasons alone, I am inclined to reject the notion that Blackness, Black people, and Black bodies are wretched, regardless of where or how they exist. In a society that sees you as a threat, Black privacy, however intangible it might seem, is all you have. White Fear and the Gaze of White Supremacy When I grabbed him [Michael Brown, the unarmed eighteen-year-old young Black boy], the only way I can describe it is I felt like a five-year-old holding onto Hulk Hogan. When he looked at me, he made like a grunting, like aggravated sound and he starts, he turns and hes coming back towards me, His first step is coming towards me, he kind of does like a stutter step to start running. When he does that, his left hand goes in a fist and goes to his side, his right one goes under his shirt in his waistband and he starts running at meHe was almost bulking up to run through the shots, like it was making him mad that Im shooting him, Wilson said. And the face that he had was looking straight through me, like I wasnt even there, I wasnt even anything in his way. This is where Wilson focused his shot placement at Browns head, killing the unarmed teen. I remember his feet coming up and then they rested. 19 -Ex-officer Darren Wilson On the day Michael Brown Jr. was shot and killed, August 9, 2014, I was left wondering if the fear that often encompasses the Black body generates a desire to destroy it wherever it resides. Yancy emphasizes that killing the Black body is an act that functions to provide the white body with an omnipotent consciousness, giving whites the illusion of absolute power to take a Black life. 20 We see and hear the destructive dynamics of white fear that have transformed into a type of cultural fear that was carried out in Darren Wilsons horrific imaginative fantasy depicted above, especially when the Black masculine body is deemed a threat or out of place. Darren Wilson, Grand Jury testimony, Washington Post, Nov. 26, 2020. [Please provide an article title (and an author, if available)] 20 Yancy, Black Bodies White Gaze, 116. 19 18 The practice of Black privacy is also a response to the physical and metaphysical containment and violent nature in public Blackness and Americas carceral systems that treat Black people as nonhuman. Fear of the Black masculine body must exist to rationalize policing it to death through the hegemony of the white gaze. For this reason, the Black body must be always controlled by those who benefit from what is often referred to as white-supremacist power structures. Public Blackness is a metaphysical extension of both the systems of slavery and Jim Crow in reference to their carceral aim against Black people. 21 Like the systems of slavery and Jim Crow, public Blackness creates a carceral reality where Black people are constantly in conversation with the demoralizing distortions of their presence in the world and with how their bodies are controlled at every stage of their existence. 22 These distortions frequently arise from how the gaze of white supremacy apprehends Black bodies. The gaze of white supremacy views Black people as foreign objects that are not to be trusted and are inherently criminal or deviant. The gaze functions within the realm of public Blackness at the individual gaze level or the social gaze. Both, one could argue, have been bombarded with anti-Black ideologies that dehumanize the presence of the Black body. When trying to understand the cynical connotations ascribed to the Black body, we must also consider how Blackness or the darkness of ones flesh, and the fear that ensues, generates an unsettling sense of understanding how society views ones presence in the world for Black people (i.e., corporeal politics). Blackness in an anti-Black society encompasses both Black people and the being of Black people. 23 The gaze of white supremacy identifies Black bodies as a danger to white society. Some Black people become hypervigilant about the gaze. Most Black people have a collective understanding of the inner functions of white fear, particularly when that fear is projected onto their bodies. Jason M. Williams, Race as a Carceral Terrain: Black Lives Matter Meets Reentry, Prison Journal 99, no. 4 (May 2019): 390. https://www.doi.org/10.117/0032885519852062. 22 Ibid. 23 Hart, Dead Black Man, Just Walking, 94. 21 19 White fear, as Eddie Glaude Jr. explains, is the general frame of mind that Black people are dangerous, not only to white individuals because they are prone to criminal behavior, but to the overall well-being of our society. 24 Glaude argues that such fears can produce cycles of racial moral panic in which Black people are viewed as a threat to everything we [white society] hold dear. 25 The notion of white fear when concerning the existence of Black bodies and Black people becomes something anticipatory, a fear just waiting to be expressed. 26 One must consider that public Blacknessthe very presence of Black people in publiccan propel acts of violence. 27 For instance, when the Black body finds itself enmeshed within public Blackness, it provokes an anguishing sense of vulnerability to white bodies. This often depends on how the gaze positions the Black body in specific communal spaces. In public, the Black body lacks the freedom to experience its existence without compromising with anti-Black connotations imputed to its flesh by the white gaze. Taylor, Floyd, and Arbery all died in 2020 as a result of the same fear that killed Brown in 2014. Fear has been assigned the task of destroying and containing the Black body, which is seen as a problem rather than a human. Eddie Glaude Jr., Democracy in Black: How Race Still Enslaves the American Soul (New York: Broadway Books, 2017),75. 25 Ibid.,76 26 Ibid. 27 Ibid. 24 20 Escaping Americas System of Punishment From slaves codes to Black codes to segregation laws to the codes of color-blind racism, Black people have been constructed by an incarcerating -and- carceral gaze. 28 -William David Hart The Black body lives in Absence, argues Lewis R. Gordon. 29 Whenever the Black body is present or converts from Absence to Presence, it poses a threat to the precarious balance of reality for white bodies that are already present and therefore poses no such threat except, perhaps, in his absence. 30 The relationship between the perception and policing of Black bodies works to eradicate anything that jeopardizes white society. For instance, the hegemonically repressed history of lynching in America, which white-supremacist power structures have virtually tried to erase from public memory, presents a context for understanding the brutish nature of how the Black bodies are policed today. Lynching in Americaconcerning Black peoples historical presence, especially that of Black men and boysspoke volumes to the edifice of white anti-Black behavior. The fear of Black men and boys, both historically and today, has been employed to suppress, profit from, manipulate, and eliminate what is regarded as the most vulnerable threat to society: the Black masculine body. The essence of white fear in a racialized society is a kind of political fear. 31 For Black men and boys, this specific fear was frequently induced by the emphatic beliefs held by white America about who they are and about what theyre capable of. 32 The perception of who they were was brought about by fraudulent claims that Black people were inferior, and what they were capable of was often imagined in terms of the Black phallus threatening white womens bodies. After emancipation, the ferocity of white fear, especially about the Black mans sexual yearning for the flesh of white women, was used Hart, Dead Black Man, Just Walking, 94. Lewis R. Gordon, Bad Faith and Antiblack Racism (New Brunswick: Humanities Press, 1995), 100. 30 Ibid., 103. 31 Glaude, Democracy in Black, 74. 32 Ibid. 28 29 21 to justify the uncontainable terror all through the southern region of the United States. The aspiration to prove that Black people, in particular males, were uncivilized and brutish shifted into an obsession for many white Americans. According to Ronald Jackson II, it was indoctrinated into the social consciousness of the Deep South that the Black mans primary objective was raping white women. 33 Jackson also argues that the Black body of the brute was scripted to be nothing less than an indiscreet, devious, irresponsible, and sexually pernicious beast. 34 As Rasul Mowatt argues, lynchings of Black Americans were done to curb the Black savage (emphasis added)and protect the sanctity of white womanhood. 35 The false impression that Black people were racially inferior permeated the white press and the vestibules of the ivory towers of Americas colleges and universities. From the Eurocentric religious fabrication of the noble savage to the philosophical and scientific myths of racial inferiority, the Black body stands at the center of the historical discourse around race and racism in America. The violence that followed the mythical social labeling of Black peoples bodies and, in particular, Black men and boys, is one phenomenon that remains to taint the social and political makeup of America. According to data collected by the Equal Justice Initiative, between the years 1877 and 1950 more than 4,875 Black people died by lynching. 36 This particular era in American history tends to be ignored and is the least understood. Lynching was an accepted practice utilized to dictate the Black community and the Black body and is the precursor to the modern criminal justice system in the United States. According to Donald Jackson, Scripting the Black Masculine Body, 41. Ibid. 35 Rasul A. Mowatt, Lynching as Leisure: Broadening Notions of a Field, American Behavior Scientist 56, no. 10 (Oct. 2012): 1367. https://www.doi.org/10.1177/0002764212454429. 36 Lynching in America: Confronting the Legacy of Racial Terror, Equal Justice Initiative, https://eji.org/racial-justice/legacy-lynching. 33 34 22 L. Grant, lynching was a practice which first appeared in America during the colonial period. 37 This practice was the most practical way of maintaining the racial cast system which developed after Reconstruction. 38 Lynching was so prevalent in America that it was considered a proper precursor to the establishment of legally constituted courts. 39 According to George Fredrickson, lynching was a way of using fear and terror to check dangerous tendencies in a Black community considering to be ineffectively regimented or supervised. 40 The history of lynching in America, as Jonathan Markovita asserts, has provided a lens or a way of seeing and understanding contemporary relations and spectacles of racialized violence. 41 The nature of lynching as a public spectacle compels us to severely consider the evolution of the white gaze and its role in dehumanizing and criminalizing the Black body. If we turn our attention to lynching photographs and the consequence of publicness as it pertains to Black bodies, we are then forced to understand the need for Black privacy. One could argue that lynching photos are Americas cartouches of the past. Lynching photographs speak a loud language of silence. Traces of darkness detach the contorted human figure from the background of the bleached-out faces and create a three-dimensional appearance that draws the reader. Most lynching photographs display a wide range of Black shades that offer life to the lifeless. Even though the victims were not seen as human, to us as readers, they are more human than those surrounding them. According to Mowatt, lynching photographs were created to reflect the ideology of white superiority through Black subjugation. 42 The disfiguration of Black bodies was a performance that symbolized Donald L. Grant, The Anti-Lynching Movement: 18831932 (San Francisco: R and E Research Associates, 1975), 1. 38 Ibid. 39 Ibid., 1. 40 George Fredrickson, The Black Image in the White Mind: The Debate on Afro-American Character and Destiny, 18171914 (Hanover, N.H.: Wesleyan University Press), 272. 41 Jonathan Markovitz, Legacies of Lynching: Racial Violence and Memory (Minneapolis: University of Minnesota Press, 2004), 67. 42 Mowatt, Lynching as Leisure, 1367 37 23 the communal domination and restraint of the Black body. This history forms the foundation of statesanctioned violence against Black people in the 21st century. Such sadism at one time was deemed a justifiable way of administering the law. David Garland emphasizes that it becomes rather challenging when interpreting something so gruesome as legitimate actions. 43 This can be due to how we construe the body expressions, dress, and positions of the spectators and presumed executioners. Mowatt reminds us that even though lynching was a form of vigilante justice, it was also a practice of leisure. He writes, Race, race relations, racism, and racial violence are elements that could be seen through viewing and reading lynching as a historical form of leisure. 44 The normality of lynching was distinctly American as baseball games and church suppers. 45 One could further argue that lynching photographs were symbolic representations of the antiBlack gaze, in which white subjects generally viewed black subjects as objects to be feared and controlled, even to death. To be the receiver of such fear, especially during the post-emancipation era, was to grapple with the Others fear of ones existence. The Black body at the focal point of lynching campaigns was hauled into the fetishistic condition that was often associated with this vigilante act of justice (i.e., lynching). Lynchings were always preceded by a ceremony that went largely undiscussed. Lynching mobs would frequently dismember the Black body and sell its pieces as relics to and for spectators. As Harvey Young stresses, the magic of the souvenir anchors itself in its status as contrabands, from a given place or an event. This is why the body parts as keepsake trumps postcards or pictures of the same lynched body. 46 David Garland, Penal Excess and Surplus Meaning: Public Torture Lynchings in TwentiethCentury America, Law & Society Review 39, no. 4 (2005): 794. 44 Mowatt, Lynching as Leisure, 1366. 45 Philip Dray, At the Hands of Persons Unknown: The Lynching of Black America (New York: Random House, 2002), 18. 46 Harvey Young, The Black Body as Souvenir in American Lynching, Theatre Journal 57, no. 4 (2005): 646. 43 24 The white-supremacist gaze, emblematized in lynching, seeks to uproot the Black body physically through acts of violence and metaphysically by constructing Black people as uncivilized. This perception has developed into a phobia for a large portion of white America. As discussed in the preceding section, to better understand how the gaze works within public Blackness and society, we must first consider the complicated relationship that the white gaze has with the Black body. The white gaze is what William Hart refers to as the criminogenic gaze, in which Black people, especially Black males, are regarded as criminal. 47 When the Black body is considered criminal, it must be contained not only spatially but also within our collective imagination concerning how and where it should appear. When we examine the carceral impact and abuse directed at the bodies of Black men and boys living in impoverished urban areas since the Civil Rights Movement, we can see the continuing effects of Harts conception of the criminogenic gaze concerning what Tommy J. Curry refers to in The ManNot: Race, Class, Genre, and the Dilemmas of Black Manhood in relation to the omission of Black men and boys from our society. The changing American economy during the 1970s and 1980s, according to Curry, had a significant effect on the economic mobility of Black men living in the United States. 48 In the second half of the twentieth century, the postCivil Rights economic prospects for Black men, who had traditionally been blue-collar workers and laborers, were marked by poverty and growing unemployment. 49 According to Currys reflection on Amadu Jacky Kabas 2008 essay Race, Gender, and Progress: Are Black American Women the New Model Minority? Black men have not made as much progress out of poverty as their female counterparts, who have made tremendous economic, political, and educational strides in recent decades. In many ways, their position indicates only further Hart, Dead Black Man, Just Walking, 95. Tommy J. Curry, The Man-Not: Race, Class, Genre, and the Dilemmas of the Black Manhood (Philadelphia, PA: Temple University Press, 2017), 106. 49 Ibid. 47 48 25 social and political marginalization. 50 However, according to Currys analysis of a study conducted in the late 1970s by James B. Stewart and Joseph W. Scott, they observed that because Black men are racialized men, they are subjected to deliberate and institutional programs to remove them from society. 51 The notion of eradicating the Black men and boys from society connects lynching to control the Black masculine body to modern policing and imprisonment of the Black masculine body. Both entities have played a significant role in the systematic attempt to erase the bodies of Black men and boys in our society. In their 1978 essay The Institutional Decimation of Black American Males, both Stewart and Scott reflect on a question raised by Jacquelyne Jackson and American Sociologist: Where are the Black Males? According to Stewart and Scott, this question was prompted by Jacksons examination of the ratio of Black males to Black females in major cities, which revealed that in 1970, there were only 85 Black men for every 100 Black women in the Black population aged 25 to 64. 52 In 1970, the sex ratio for the child-bearing age group (1544) was 87, indicating that the lack of Black males is not due to high mortality rates among elderly Black men. 53 This essay claims that Americas carceral system destroys Black families, removes fathers from homes, and makes Black men, both literally and figuratively, a disenfranchised and unemployed undercast. 54 However, according to Stewart and Scott, At first glance, the long-term persistence of a dramatic imbalance in the sex ratio among Blacks, as well as its precipitous decline since 1920, might appear to be a natural phenomenon associated with American society, as a similar trend can be seen among whites. This analysis, on the other hand, tries to show that the primary factor causing a sex imbalance among Blacks is the coordinated operation of various institutions in Ibid. Ibid. 52 James B. Stewart and Joseph W. Scott, The Institutional Decimation of Black American Males, Western Journal of Black Studies 2, no. 2 (1978): 82. 53 Ibid. 54 Curry, Man-Not, 107. 50 51 26 American society that systematically remove Black males from the civilian population. 55 For Curry, Stewart and Scott maintained that the institutional decline of Black men through police violence and incarceration emerged from a political economy that deliberately confined young Black men to poverty, exploited Black males for cheap labor, and rationalized their death as a consequence of their deviance and undesirability in American society. 56 In a report published in the American Sociological Review in 2004, the U.S. penal population increased sixfold between 1972 and 2000, leaving 1.3 million men in state and federal prisons by the end of the century. 57 Around 12 percent of Black men in their twenties were in prison or jail by 2002. Researchers claimed that prison time had become a normal part of early adulthood for Black men in poor urban neighborhoods due to high incarceration rates. 58 According to the most recent study conducted by the U.S. Department of Justice in 2019, the imprisonment rate of Black adults at the year-end 2019 was more than five times that of white adults (263 per 100,000 white adult U.S. residents) and almost twice the rate of Hispanic adults (757 per 100,000 Hispanic adult U.S. residents). 59 Both the historical practice of lynching and the contemporary practice of policing, surveillance, and imprisonment to control the Black masculine body have the same objective in mind: to eradicate what is most feared about the Black masculine body. To escape Americas system of punishment is to escape both death and isolation. Stewart and Scott, Institutional Decimation of Black American Males, 82. Curry, Man-Not, 107. 57 Becky Pettit and Bruce Western, Mass Imprisonment and the Life Course: Race and Class Inequality in U.S. Incarceration, American Sociological Review 69, no 2 (April 2004): 151. https://www.doi.org/10.1177/000312240406900201. 58 Ibid. 59 Prisoners in 2019, Bureau of Justice Statistics, last modified Oct. 2020, https://www.bjs.gov/index.cfm?ty=pbdetail&iid=7106 55 56 27 As previously noted, the desire for Black privacy is a manifestation of the difficulty of living in two worlds, which becomes a concern when the Black masculine body enters white social spaces and society as a whole. Frantz Fanon reminds us that in the white world, the man of color faces difficulties in elaborating his body schema. 60 The self-image of ones own body is entirely negative. A pervasive sense of unease permeates the body, causing it to question its existence. The advantages of Black privacy include the potential for the Black body to avoid an atmosphere of certain uncertainty, where the body no longer becomes an object among other objects, but purely human. 61 Simply put, Black privacy becomes an internal space where one can focus on life while selflessly reclaiming what is continually disfigured and destroyed: the Black bodys very presence in the world. In response to this anti-Black structure of public Blackness and Americas anti-Black carceral practices, the Black body is forced to adapt to complicated mechanisms of surveillance. From slave codes to Black codes to segregation laws to the codes of color-blind racism, Black people have been constructed by an incarcerating -and-carceral gaze. 62 The question then becomes, how can Black privacy protect and sustain the Black body in public Blackness? Black Privacy and the Sustainability of the Black Body For the Black body to sustain itself, Black privacy must safeguard the Black body from the dominating nature of public Blackness. For some Black people, public Blackness may lead to a fracturing of their identities to survive. W. E. B. Du Bois called this phenomenon double consciousness, an existential state in which one inhabits two worlds in one dark body. This Frantz Fanon, Black Skin, White Mask (New York: Grove Press, 1967), 90. Ibid. 62 Hart, Dead Black Man, Just Walking, 94. 60 61 28 perception of self, pushes the Black body into a state of absence. 63 When the Black body is in a fragmented state, the notion of the self must become nonexistent to itself if it chooses to live within the domain of public Blackness. Consequently, public Blackness produces this state of double consciousness, forcing the Black body to negate itself or reject its existence to be public. As Yancy argues, the Black body through the hegemony of the white gaze undergoes a phenomenological return that leaves it distorted and fixed as a pre-existing essence. 64 The internalization of this misrepresentation by Black subjects brings them to perceive themselves in the way they have been imagined by the white gaze: as an object to be feared. Public Blackness demands the Black body either comply with this warped, anti-Black perspective or wither into a state of hopelessness. As Hart explores in his analysis of the demands imposed on Black people by the white-supremacist gaze: Black people are induced to normalize the gaze of white supremacy, to internalize the surveillance, to discipline and punish themselves. In concert with the criminal justice system, [carceral regimes] the dynamics of the carceral American imagination, Black Americans are regarded with animosity, contempt, and suspicion. Even small groups are regarded as insurrectionary or riotous. 65 Public Blackness, therefore, coerces Black people to embrace and normalize the gaze of white supremacy. 66 The Black body undergoes a phenomenological return due to the white gazes control, rendering it distorted and fixed as a pre-existing essence. 67 As Fanon describes in his reflection about what he experiences when he meets the gaze of the Other: Locked in this suffocating reification, I appealed to the Other so that his liberating gaze gliding over my body suddenly smoothed out rough edges would give me back My use of the term absents implies that the black body, when caught in public blackness, becomes so conscious of its position within it, that it seeks to become invisible to move about. 64 Yancy, Black Bodies White Gaze, 109. 65 Hart, Dead Black Man, Just Walking, 94. 66 Yancy, Black Bodies White Gaze, 109. 67 Ibid. 63 29 the lightness of being I thought I had lost, and taking me out of the world put me back in the world. 68 According to Fanon, the gaze has the power to influence the bodys movement in the world and the way the body appears to itself. 69 This, I might add, is only possible if the Black body, as the subject, embodies the gaze of the Other, as well as its perspective and imagery. Black privacy is an approach that allows Black people to avoid public Blackness and its systemic violations of the Black body by defending how Black people recognize their own position in the world, ontologically speaking. Public Blackness shapes the Black body in ways that are harmful to Black people who cross its course. The Black body is viewed as deviant and a danger to the social order within the constraints of public Blackness. This fearful white-supremacist imaginary justifies the carceral regimes that are summoned to police and murder Black people at will. The mere presence of Black bodies within white public spaces (i.e., suburban communities, social spaces, schools, college and university campuses) petrifies what Hart calls the whiteopian dream; an imaginary (utopian) space devoid of Black people. 70 Black privacy becomes a response to societys neurotic behavior toward the Black body, which Black people themselves cannot avoid. When the Black body becomes visible within the structure of public Blackness, it becomes marked for death (i.e., Trayvon Martin, Tamir Rice, Botham Shem Jean, Eric Garner, John Crawford III). Public Blackness compels us to ask, What does it mean to be killed by the American imagination? When a Black body is out of place in white spaces, it must be destroyed either metaphysically or physically by the state. Dead Black bodies, whether physically and metaphysically, are needed in order to magnify white existence. 71 The ontological fear that the Black body experiences are the Fanon, Black Skin, White Mask, 89. Ibid. 70 Hart, Dead Black Man, Just Walking, 100. 71 Ibid., 116. 68 69 30 consequence of having to live in public Blackness. According to Hart, Black body existence does, in fact, mean killing Black bodies. 72 Fear of dying in public due to being Black leads some Black people to become hypervigilant and seek refuge in Black privacy. The mere idea of being engulfed in public Blackness can be disruptive to ones well-being, triggering a slew of health problems. The Black body is forced to either flee or maneuver inside public Blackness. In any case, Black privacy is required to protect the Black body from the violence within public Blackness, especially when it is perceived to be out of place. According to Hart, in American society, Black bodies that appear out of place are threatening. 73 They threaten to pollute the space they inhabit through various kinds of contagion (especially crime). Whether Black people live there or not, Black bodies do not belong in whitopian spaces. 74 The epitome of white-utopian spaces that tend to criminalize Black people and their bodies is public Blackness. Blacks in social spaces are regarded as an invasive species that needs to be carefully monitored, controlled, and possibly uprooted. 75 In attempting to defy Black publicness through Black privacy mechanisms, the Black body is bound to adjust to white distortions of its presence while trying to diminish them. In this manner, the Black body finds itself imprisoned within the white imagination. This is where the body is confronted by a warped image of itself, facing a reality held together through white bad faith and projection that is ideologically orchestrated to have no trace of its social and historical construction. 76 One thing that the deaths of Taylor, Floyd, Arbery, and countless others have shown us is a consequence of being Black in public that forces one to want to be isolated. Whether the Black body Ibid. Ibid., 94. 74 Ibid., 100. 75 Ibid., 95. 76 Yancy, Black Bodies White Gaze, 100. 72 73 31 is in motion or motionless, no matter how young or old, no matter if it exists as male or female, no matter if it is asleep or awake, one could maintain it will forever be perceived as a problem. 32 Bibliography Pettit, Becky and Bruce Western. Mass Imprisonment and the Life Course: Race and Class Inequality in U.S. Incarceration. American Sociological Review 69, no 2 (April 2004): 15168. https://www.doi.org/10.1177/000312240406900201. Curry, Tommy J. Killing Boogeymen: Phallicism and the Misandric Mischaracterizations of Black Males in Theory. Res Philosophica 95 (April 2018): 23672. Curry, Tommy J. The Man-Not: Race, Class, Genre, and the Dilemas of the Black Manhood. Philadelphia: Temple University Press, 2017. Dray, Philip. At the Hands of Persons Unknown: The Lynching of Black America. New York: Penguin Random House, 2002. Fredrickson, George. The Black Image in the White Mind: The Debate on Afro-American Character and Destiny, 18171914. Hanover: Wesleyan University Press, 1971. Garland, David. Penal Excess and Surplus Meaning: Public Torture Lynchings in TwentiethCentury America, Law & Society Review 39, no. 4 (2005): 794. Glaude Jr., Eddie. Democracy in Black: How Race Still Enslaves the American Soul. New York: Broadway Books, 2017. Gordon, Lewis R. Bad Faith and Antiblack Racism. New Brunswick: Humanities Press, 1995. Grant, Donald L. The Anti-Lynching Movement: 18831932. San Francisco: R and E Research Associates, 1975. Hart, William David. Constellations: Capitalism, Antiblackness, Afro-Pessimism, and Black Optimism. American Journal of Theology & Philosophy 39, no. 1 (2018): 20. Hart, William David Dead Black Man, Just Walking. In Pursuing Trayvon Martin: Historical Context and Contemporary Manifestations of Radical Dynamics, 91100. Edited by George Yancy and Janine Jones. Lanham, MD: Rowman & Littlefield Publishing, 2013. Jackson, Ronald L. Scripting the Black Masculine Body: Identity, Discourse, and Racial Politics in Popular Media. Albany: State University of New York Press, 2006. Markovitz, Jonathan. Legacies of Lynching: Racial Violence and Memory. Minneapolis: University of Minnesota Press, 2004. Mowatt, Rasul, Lynching as Leisure: Broadening Notions of a Field. American Behavior Scientist 56, no. 10 (Oct. 2012): 1367. https://www.doi.org/10.1177/0002764212454429. Omi, Michael and Howard Winnant. Racial Formation in the United States: From the 1960s to the 1990s. New York: Routledge, 1994. 33 Polizzi, David Social Presence, Visibility, and the Eye of the Beholder: A Phenomenology of Social Embodiment. In Pursuing Trayvon Martin: Historical Context and Contemporary Manifestations of Radical Dynamics, 17381 Edited by George Yancy and Janine Jones. Lanham, MD: Rowman & Littlefield Publishing, 2013. Sharp, Christina. In the Wake: On Blackness and Being. Durham: Duke University Press, 2016. Williams, Jason. Race as a Carceral Terrain: Black Lives Matter Meets Reentry. Prison Journal 99, no. 4 (May 2019): 39095. https://www.doi.org/10.117/0032885519852062. Yancy, George. Black Bodies, White Gaze: The Continuing Significance of Race. Lanham, MD: Rowman & Littlefield Publishing, 2008. Young, Harvey. The Black Body as Souvenir in American Lynching, Theatre Journal 57, no. 4 (2005): 646. 34 II. PROSE 35 Memories in Translation, Part 2: Herta Gerber Testimonial and the Italian Holocaust Edited by Valentina Concu and Wesley R. Bishop Translated by Valentina Concu Introduction: In our Fall 2020 inaugural issue, we at The North Meridian Review offered the first of a series of two Holocaust survivors testimonies. These translations of Oskar and Herta Gerber, two Jewish Europeans imprisoned by fascists at Ferramonti di Tarsia from 1941 to 1943, provide a key insight into the experiences of Jewish folk during the Italian Holocaust. Oskar and Herta met in this camp upon Hertas arrival, fell in love with each not long after meeting, and spent the rest of their lives together following the war. The testimony of Oskar that we published last year was an examination of the Italian fascist regime and how the country implemented its infamous racial laws against its own Jewish population. 77 Hertas testimony complements Oskars descriptions of fascist Italy while also describing her own experience of forced removal from the Polish city of Bielsko to the concentration camp in southern Italy. 78 Hertas memories will also add to the understanding of Italys behavior toward its own Jewish citizens and the European Jews that were captured and imprisoned in the Italian campsdisplaying open hostility and anti-Semitism but often not with the same ferocity as their German counterparts. The New York Times reported on such behavior, highlighting how, on one hand, Italian and European Michele Sarfatti, Jewish in Mussolinis Italy: From Equality to Persecution (Madison, University of Wisconsin Press, 2006). 78 Today Bielsko is situated in the western part of the city Bielsko-Biaa in Poland. It was an independent town until 1951. 77 36 Jewish folk lost many of their civil rights because of the racial laws. On the other hand, the Italian regime did not perpetrate the same type of executions in its concentration camps as did the infamous German ones. 79 As we mentioned in the introduction to Oskars testimony, the English translations of Oskar and Herta Gerber were commissioned in 2019 by one of Hertas relatives, who received the original interviews in Italian from the Shoah Foundation. The name of this relative is Joyce Field, a prolific Jewish genealogist. For the conclusion of this series we were honored to sit down and interview her for this issue of The North Meridian Review: Concu & Bishop: Dear Joyce, could you briefly introduce yourself? Where were you born? Where did you go to school? What was your major? Joyce: I was born in Bronx, New York, and we moved to Detroit when I was about 4.5 years old. I received my B.A., graduating summa cum laude at Wayne State University, in Detroit. I majored in English literature, with minors in Italian and Sociology. My graduate work was at Indiana University and Purdue University, where I focused on English and American literature and literary criticism. Concu & Bishop: How did you end up in Indiana? What were your first impressions of the Midwest? Joyce: My husband and I both received graduate teaching assistantships at IU. It was very challenging in the 1950s for a married couple, both majoring in the same field, to receive teaching assistantships at the same department. The Bloomington campus was gorgeous, and I loved the bucolic atmosphere after living in gray midtown Detroit. Then we received jobs at Purdue University. Well, Dutch elm disease had just killed all the lovely trees lining State Street and the campus was like a barren desert. My reaction was the opposite of what I felt about Bloomington. To console me my husband said that we would stay only one year, but here I am 64 years later. Concu & Bishop: What do you currently do? I am retired from paid employment. But I am active in political and cultural areas. I chair the redistricting reform committee for the League of Women Voters Greater Lafayette, and I am the Metropolitan Opera Live in HD Ambassador for the Lafayette area with a mailing list of 160+ opera lovers. I also maintain my involvement with genealogy by being a consultant with JewishGen. Concu & Bishop: How did you live the last four years with Trumps presidency? Scholars Reconsidering Italys Treatment of Jews in the Nazi Era, New York Times, Nov. 5, 2010, p. A28. 79 37 Joyce: Not well! I spent too much time reading about the daily insults to civil society and bemoaning the destruction of causes that I had fought for in the 1960s and 1970s. I spent too much unproductive time emailing people of like values about the latest Trumpian horrors. I donated money to liberal candidates and political action committees and to activities trying to overturn gerrymandering. My son called me Don Quixote, but I said I had to do what I could to achieve a more just society. Concu & Bishop: Could you talk about your activity and work as a genealogist? Why did you decide to embark on such an activity? Joyce: I got inspired in the mid-1990s. I had retired and purchased my first Apple computer. The internet as we know it didnt yet exist. All we had was a dial-up connection which was quite expensive because the connections were slow, and you had to buy time by the minute and hour. I was just browsing when I came upon the United States Holocaust Memorial Museum site and a datafile on transports to Auschwitz. I remember it was a cold winter day, and I was dressed in a wool plaid skirt, an Aran turtleneck sweater, and warm tights. I had a steaming cup of coffee on my desk, and the sun was shining brightly through my window reflected on the heavy white snow. A cardinal was sitting on a tree branch. I recall this background because of the contrast between the horrors of the concentration camp transport file and my warm comfortable home. My brain was flooded with images of the cold, starving Jews in the cattle cars to Auschwitz compared with my life. It was an ah-ha moment. I knew instantly that I had to be involved in Holocaust research. Of course, my husband and I had read and studied about the Holocaust for decades, but nothing was as vivid and soulwrenching as seeing the transport lists on my small computer screen. I then started searching for more Holocaust material, and in a short time I discovered JewishGen, an online Jewish genealogy site. They were looking for volunteers, and I immediately wrote to them. When I described my background, they brought me aboard. I assumed more and more responsibilities and developed cooperative relationships with other organizations worldwide to secure data that could be converted to searchable databases for researchers. I was promoted to VP for Data Acquisition and Research and oversaw three important projects: the Yizkor Book Translation Project, the Worldwide Burial Registry, and the Holocaust Database. The purpose of the Yizkor Book project is to translate into English the many hundreds of these memorial books on European towns whose Jewish population was murdered by the Nazis. These books contain some of the most important information on these destroyed communities. The JewishGen Online Worldwide Burial Registry (JOWBR) is a database of names and other identifying information from Jewish cemeteries and burial records worldwide, from the earliest records to the present. It is a compilation of two linked databases: a database of burial records and a database of information about each particular cemetery. JOWBR aims to catalog extant data about Jewish cemeteries and burial records worldwide. JewishGens Holocaust Database is a collection of databases containing information about Holocaust victims and survivors. It contains more than 2.75 million entries, from more than 190 component datasets. 38 Why did I dedicate 12 years of my retirement to Jewish genealogy? It became a mission to recover the names and fates of Jews whose identities the Nazis intended to obliterate. They and their lost worlds should not be forgotten. Concu & Bishop: What does it mean to you to be a descendent of survivors? Joyce: It is very difficult to explain my feelings: gratitude that my parents had the courage to leave Europe for the US with no money, no language skills, minimal job skills. I dont know if I would have had their strength, fortitude, and belief in a better life here. I also am forever sad and angry that most of the relatives who did not immigrate did not survive and that I never knew them. I guess the emotions are anger and sadness. And I live with admiration for my parents lives. Concu & Bishop: Why it is important to keep talking about the Holocaust and its survivors? Joyce: The Holocaust is not only a horrific historical event but a warning to the world that it could happen again, that those horrible dark forces could unleash similar events. What happened on January 6th could be a harbinger of the future, as Timothy Snyder pointed out. 80 Jews are taught the importance of memory, of being witnesses. We are taught to be the guardians of memory so that the world will learn and never forget. Concu & Bishop: Could you tell us who Oskar and Hertha were and your relation to them? Joyce: Oskars father and my mother were siblings. Oskar was one of the oldest of twelve children and my mother was the youngest. My mother spent part of World War I living in Budapest with Oskars family, and she was like a nanny to Oskar. My mother and the other siblings who had immigrated to the US tried to get Oskars parents, his siblings, and his wife visas for the US before World War II began, but it was very complicated because Herta had a Polish passport while all the others had Hungarian passports. As a result, they were on separate quotas. Concu & Bishop: What do you think these interviews represent in todays world? Joyce: They are a reminder and a warning. This could happen again. Trumpism was frightening to me as it reminded me of the 1930s in Europe and even the U.S. The rhetoric, the anti-Semitism, the nativism, the white supremacists, the religious bigotry, the fear mongering, etc. We are not out of the woods yet. Witness the political situation in Poland and Hungary. We still have the KKK, the Proud Boys, QAnon, and other groups here. We cannot blind ourselves to the hate and the fascist white supremacists here. Here she is referring to the January 6, 2021, insurrection at the US Capitol Building by Donald Trump supporters and far-right-wing groups trying to overturn the presidential election results. Timothy Snyder is the Richard C. Levin Professor of History at Yale University who, during the Trump presidency, wrote prolifically on the dangers of encroaching fascism in the United States. 80 39 To help the world to never forget the horrors of the Holocaust and the threat of fascism, in a season not long after an attempted coup at the U.S. Capitol Building which reminded many of the political turmoil of the 1920s and 1930s in Europe, we at The North Meridian Review are pleased to present Hertas testimony for the first time translated into English. May we never forget, and never fail to rally against these destructive forces. *** Interviewer: Today is April 14, 1998, and Im interviewing Herta Gerber Bratspiess. The interviewer is Maurina Alazraki. We are in Milan, in Italy, and the interview will be in Italian. Good morning, could you tell me your name? Herta Gerber: My name is Herta Bratspiess Gerber. Interviewer: When were you born? Herta Gerber: I was born on the 23rd of September 1922 in Bielsko, Poland. Interviewer: Could you tell me a little bit about your family, your parents? Herta Gerber: My parents worked in commerce, my dad had a dental warehouse and he supplied all the dentists and doctors in the area. My mom would help out, and my dad would travel a lot. We were kids and we went to school, first the Jewish school, then high schoolwe had to go to a cloister, which was safer because they would attack us in the public school because we were Jews. Interviewer: What was the name of your dad? Herta Gerber: My dads name was Paolo Schuling, in Yiddish, and my mom Amalia. We lived in the same building where my grandparents lived. Interviewer: Did you have any sisters? Herta Gerber: Yes, a sister, who now lives in Israel. Her name is Lili, Lea Schaffran. She has a daughter, who is married, and two grandchildren. Interviewer: Is your sister older than you? Herta Gerber: Yes, she is. She is two years older than me. Until the end of the war in Italy, we stayed together. Then they moved; they did the Aliyah and went to Israel. My parents too, around one month after they went there. 81 Aliyah is the historical immigration of the Jewish people to the land of Israel, which corresponds today to the modern state of Israel. 81 40 Interviewer: Could you describe to me your house? Where did you live exactly? Herta Gerber: We livedwell, Bielsko was kind of an important city for the production of fabrics; we lived in a beautiful area, the entire building was owned by my grandma, so we lived very well there. Interviewer: Did other Jewish families live there? Herta Gerber: Yes. On the first floor, there was a Jewish family. On the ground floor, there were Catholics. And living together was good enough. There werent a lot of Jewish houses close to us; this square was a little bit isolated, because there was a big fabric industry, and the owners were friends of my grandparents. We lived well, we felt safe, although sometimes there were some problems against the Jewish residents; the attacks would come from the side of Polish people. Interviewer: To which school did you and your sister go? Herta Gerber: The elementary school was a Jewish school. Later, we went to high school, it was called the Humanistic School. Interviewer: What kind of Jewish school was it? Could you describe your school to me? Herta Gerber: The school was kind of traditional, with religious rituals, they educated us with religion classes. I took a Hebrew class that I liked very much. It was a good school; we were among us. I have to admit that, although we lived in Poland, the language we used at home was German. Interviewer: So, you spoke German at home? Herta Gerber: Yes, we spoke German at home. The Polish people would complain about that but my mom did not go to school in Poland, so she would speak in German, and we did that too. Interviewer: Did you also speak Yiddish at home? Herta Gerber: Yes. Our grandparents spoke Yiddish and we liked to hear it so much that, when I can, I still buy some recordings that remind us of our language, our dialect. Interviewer: Could you describe your life? You went to school, then what were your hobbies? Herta Gerber: Oh well, it was the so-called bourgeois life, we had piano classes twice a week, we had gymnastics, that was at the Makabi. Our classmates went there too. We met new people. When we were on vacation, we would go not too far to the little town in the mountains, the little lakes. We would go there with my grandma; she would bring us everywhere because my mom was always busy. She would come with us on Saturday or Sunday. I had a little cousin, who was the son of one of my aunts; it was very beautiful. Interviewer: Did you go to a synagogue? 41 Herta Gerber: Yes. In Bielsko there were many. We went to the more progressive one, and a little bit more flexible about its traditions. 82 A beautiful synagogue and I think it still exists today. And then, there were a couple more where my grandparents would go, and those were for what they believed first of all, the Hazzan 83sang very well and they liked that, and it was smaller and more private. So, we would go from one to another. Interviewer: Would you go to the temple on every Shabbat? 84 Herta Gerber: When we were going to the Jewish school, yes. Later, I would not stay for lack of time, but you know, the school was a little bit more challenging, and since we had to go to school on Saturday, because it was a Catholic school, it became almost impossible to go. But we would go for all the festivities. And back at our house, there was Kasher. 85 Interviewer: Could you describe to me the Shabbat at home? What would your mom do? Herta Gerber: Oh well, first of all, Friday evening was almost more important than Saturday. My grandma would prepare the challah. She would prepare such beautiful bread loaves, that when I buy it here by Garbagnati, which has very good bread loaves, well my grandma would do them even better. She would also prepare all the fish the way we liked it, in the Polish way, you know? Fish fillet . she would also make some broths that are not allowed today anymore. The first plate was always for my dad and that was always a lot of respect between her and her son-in-law. When we did the kiddush, the mozah, those are things that I remember with a lot of nostalgia because here, yeah, we could do it, but life has become a little Herta trails off here thinking about the food. Interviewer: Do you remember any other festivity? For instance, Pesach? 86 Herta Gerber: Oh, it was very beautiful. We would start from the attic and collect all the dishes. The glasses with the golden edges, those were red glasses made of crystal, very beautiful, for the wine. My grandpa would prepare the wine himself, with some special raisins that he would order from a shop called Delikatessen 87 and that shop would also get stuff from foreign countries. They were light-colored raisins, not the dark kind, he would cut them into little pieces and put them in very big containers of a liter or a liter and a half. He would fill those up until a particular level, and then he would put now I do not remember, he would put them on a little stove because back there, we had only those, but they were beautiful. He would start weeks in advance, and it had a unique smell. Jewish communities distinguish themselves on how strictly they follow the Jewish law. While the most traditional communities follow a specific set of rules determined by the rabbis, the most progressive ones see Jewish law more as a guideline for their daily lives. 83 The Hazzan is a Jewish cantor in a synagogue. 84 Shabbat corresponds to Saturday, and it is the weekly resting day of the Jewish people. 85 A set of dietary rules to prepare food according to the Jewish Law. 86 Pesach, also known as Passover, is a major Jewish holiday celebrated in the spring. 87 A shop that offers various types of food and pre-cooked meals. 82 42 Interviewer: So, everyone would celebrate Pesach? Herta Gerber: Yes, everyone. Then I remember, and this doesnt have anything to do with the Pesach, the pickles, that we normally buy, my grandpa would put those in big barrels with some acidic little apples which would make the pickles go naturally sour. He would put the sauerkrautbecause in Poland those were vegetables, there wasnt a lot to choose from Anyway, we would make it like this because we also had a vegetable garden that would border on the river Biaa, which divided Bielsko from Biaa, which were two separated cities back then. In this vegetable garden, he would plant everything: vegetables, flowers. We would spend hours there when he was working, but when all the vegetables were ready, we would go there. We enjoyed it a lot. Interviewer: So, you went to a Jewish school until when? You said that after that, you attended a public school? Herta Gerber: Yes, we went to a cloister. So, keep in mind that it was in 1939 when the war started, and I was starting my high school diploma. So, I went to the Jewish school 5 years before that, so it was 1934. Interviewer: Why did you change schools? Because the Jewish school was gone? Herta Gerber: Yes, there was no Jewish school anymore. I wanted to study, but then the war started in 1939. Interviewer: When you changed schools, did you have any problems because you were Jews? Did you hear Herta Gerber: Yes. My sister, who was 2 years older than me, went to public high school. The school was led by and full of people who were anti-Semites. They were all the children of officers and employees. Also, the professors, they not only didnt have any respect but they also did not care about the Jewish students in class. Interviewer: Did something happen in particular that you can remember? Herta Gerber: Yes. They would refer to us using a terrible word that they would repeat almost daily how do you say that? You know, where people who are very sick in their skin, mangy? 88 That was the word. Many Jews went back to Palestine. Well, my sister after 2 or 3 times hearing that, she hit a girl who was the daughter of an officer, someone in the military. This girl fell down the stairs, and when she went back home, she told her parents about it. The principal called my mom. My mom had already told my sister that she wasnt going back to that school. He called her and he said to her, Do you know what your daughter did? and she replied, Yes. I know, she told me. Since you are not able to protect my daughter, she had to do it herself. So, Im taking my daughter out of school. So, there was this cloister, it was a high school with a cloister, like the Marcelline and the Orsoline here. It was an Austrian one, from Vienna, Saint Hildegard, and it was a fancy school. It was kind of expensive, you know? But it was a safe school, and for the religion class, a rabbi would come. I still remember his name, Rabbi Hirschfeld. He was a rabbi with red hair, a red 88 She is referring to the term leper. 43 beard. He was the portrait of a stereotypical rabbi. He came to the school and taught where we played sports in the gym because there wasnt a crucifix there, while in the other rooms there was always one since it was a cloister. We did well there. There were also teachers of German. There was a noble lady, she was very nice, and she told us You both speak very well, I would like for you guys to join us in the garden. She knew that the Polish people at the school didnt have an opportunity to learn this language. German is hard. Interviewer: So, there were other Jewish girls in the cloister? Herta Gerber: We were the majority there. Because once we transferred to the school, the others did it too. It was also dangerous to stay in the old school. I remember that my cousin was still going there... When he would get out of school, they would hit him. We needed to go and pick him up. Those were always horrible scenes. Since my sister was a little bit quicker with her hands, she was the one who always went to pick him up. With the backpack, she would punch people on the left and the right. And this was at a time when Adolf Hitler wasnt even in power. Oh, that was Poland back then. That was an innate anti-Semitism with them. And I also remember this, that our cleaning lady would go to church on Sunday. Sometimes, she would ask us, Do you all want to come to walk around? and we would go with her, she would bring us to church and we could hear the priest from the pulpit saying, dont buy from the Jews, and this from the pulpit, after the homily, because all the Jews are communist, and they should go back to Palestine. And this in Polish, you know? And guess what, they are anti-Semitic today as well, even without Jews. Hitler wasnt there yet. That was in Poland, but it originated in Russia. A pogrom. Do you know what a pogrom is, right? We experienced that in Bielsko 89, before Hitler. Interviewer: Tell me about it. Herta Gerber: Yes, the house in which we were at, in that square. That square was all close, except for an exit on a little narrow street. And that street, which was also called narrow street enge Strae. On this street, when you would take it to reach the big street, there was a tavern of a Jew. On Saturday evening, workers would go there to eat but mostly to drink. One of them got drunk and didnt want to pay. The owners of these taverns also owned weapons because they always had to deal with drunken people. So, the owner of this tavern got scared that night because of these drunk people and shot them, injuring one of them. After that, the workers gathered together outside of the restaurant, and this started the pogrom. They started to go from one house to the other to rummage. They did not come to us because the doorman of the firm blocked the little road that would face that big street. Interviewer: How old were you when that happened? Herta Gerber: I was born in 1929, so I was 8 or 9 years old. And I remember that, after a couple of hours, you could hear it. They started burning down things, they cut the duvets because we used them on the bed. They cut them open and all those feathers. The city was full of those things flying around. And it was a pogrom. They ruined the windows of the shops, beat up people, cut beards of those people they met on the street and could not escape. For us, it was very weird because normally The pogrom in Bielsko took place in 1937. The stores owned by Jewish citizens were boycotted, and many windows were broken. 89 44 those things happened in Russia or in those little towns close to Russia, but never in a city like Bielsko. So, with this, I want to tell you that the Polish people were perfect perpetrators also without Hitler. Hitler wasnt there yet. Interviewer: There is something I would like to know. The summer of 1939. What did you all talk about at home? Was your dad worried? Herta Gerber: It was terrible. I remember that my dad wanted to pack our stuff, take all we could take, and move to Israel in Palestine. He was an old Zionist, but it wasnt possible. My mom didnt want to leave her family, my grandparents. They were old already, sick, and she didnt want to leave them. And it wasnt easy. I dont remember it anymore, but in order for you to be able to go to Israel in Palestine you had to buy something, and that wasnt easy to buy. Anyhow, when the war started, close to Danzig, the Polish government called first the Jewish people to fight at the front. Look how evil they were. If you said no, they would take your citizenship away, but if someone had to die, they would send the Jewish people first and foremost. It was the Westerplatte battle, which was in Danzig. Gdask is the Polish name for Danzig. Hitler was taking over this piece of land. They didnt want to give up, and the first to die was a Jew, and he was the son of the Jewish family who lived in our house, Morgenstern. His older brother was able to survive. The first emigrated to Israel with a backpack, I remember. He went through Turkey, and he arrived even before the 1930s, in 1927 or 1928, he entered Palestine illegally. Then he started working on the farms, collecting oranges. He is still alive today, thank God. He is old, of course. The other brother, the youngest one, he survived too. The middle one was called to serve, and he died very soon. Interviewer: So, your dad tried to get these visas to Palestine, but he couldnt? Herta Gerber: Yes, he was trying but couldnt get them. And it was already late. Then we tried to leave because they were saying that Silesia was going to be occupied by the Germans because we were so close to Germany. Then my dad had this supplier who asked him to go to Warsaw and stay at his house if we wanted to get away from Bielsko. We didnt have another way to escape, and we went there. Interviewer: When did you go to Warsaw? Herta Gerber: In August. The first ones to leave were the children and my aunts. My dad stayed there with my mom because of my grandma. My grandpa had already passed away some years before that. My grandma was very sick. When we arrived in Warsaw, we moved into the house of my dads supplier. Interviewer: This was before the war, right? Herta Gerber: It was between the last day of August and the 1st of September. The second day after we arrived, the war began. On September 1st. During the first bombing, all the glasses broke, and we slept with the windows open. The apartment had 10 rooms. My dad took the last train all the men left Bielsko. My mom stayed with my grandma because she couldnt leave her. My dad took the last train with many other Jews. That train stopped, I think, after Krakow, it didnt go any further. All the people got off and started walking. They wanted to go to Russia. They said, we are going toward Misrach. When my dad was still in the train, a ticket inspector came on, and at the time, they didnt sell train tickets anymore, there werent any ticket offices anymore. He asked my 45 dad for the tickets and my dad replied, look, no one on the train has a ticket, that is why I dont have it. And they said this train was to evacuate the area, so no ticket was needed. The ticket inspector said, No, no, you will now come with me to the station. And they started walking through the woods, and my dad thought that he was about to get killed, to get robbed and killed. He had a lot of money with him because he didnt know where he was going to end up at. But then, after a while, he let him go into the woods. After crossing through the woods, my dad arrived at a highway. But there were no cars. After a while, a car passed by, and then my dad went in the middle of that street and this was what he told us when he arrived in Warsaw He went into the middle of the street to stop the car. He saw that in the car there were two Polish officers, and they asked my dad what he wanted? My dad spoke Polish very well and said to them, Im fleeing because I was afraid to be caught by the Germans. Im going to Warsaw because my family is there. And they replied, Look, we can take you for a little bit on this road, but then we have to go another way. They were very nice, and they took him. Later, my dad tried to take another train that was still working. Anyway, he made it to Warsaw. When he got to our place, Orla Street 6, which means the eagle, he rang the bell, and we went to look out of the window because we were afraid. We saw an old man with a beard and who was messy. We didnt want to open the door, but then he started screaming, Open, open, it is me, it is dad! For me it was I had left not very long before that day and what did the man become? A part of it was fear, what he experienced, and then the trip to Warsaw. Anyway, a part of our family was there but we didnt have any news from my mom. We didnt have phones or stuff like that. So, we decided to go back, me, my aunt, and my little cousin. We arrived at the border between occupied Poland and Germany, we bought a magazine for my cousin, so he could read and hide himself behind it because he didnt look German at all. Anyway, we made it to Bielsko. It was already very late at night, and we moved like robbers, and we went home. The same thing happened with my mom. She didnt want to open the door. My grandma had already passed away and she was home alone. She was getting ready to leave because she had rented a place in Auschwitz. The Germans were saying that by the 25th of December Bielsko had to become Aryan, with no Jews. And she didnt know what to do. She said, I didnt have any news from you all in Warsaw, how could I find you without any contact? So, she rented an apartment in Auschwitz. Interviewer: Why exactly in Auschwitz? Herta Gerber: Because they said it was a beautiful city. My dad would go there very often, he had customers there doctors, dentists, technicians. My mom also had good memories of Auschwitz. It was a nice city and there were Jews there. She thought that she could be together with other Jews. When she saw us that night, she almost fainted. Interviewer: Then what happened? Herta Gerber: We went back to Warsaw but when the Germans arrived, we started to look for ways to leave. We discovered that there were some consuls that were selling some passports. They had made a business out of it. The only one who was giving out passports for free, and we discovered that later, was the Italian consul. They would also try to find some Italian ancestors for the people who applied and gave them an emergency passport because in war times one could do that without asking the country for permission. We took the passports and citizenship from Nicaragua, which were 25,000 dollars in gold. We went to the Italian consulate in Warsaw to get a visa with this Nicaraguan passport, and I remember that there was a very long line. We had the only passport that could get the visa immediately, the others had to wait. I went there with my sister, and 46 they asked us where we wanted to go, what we were going to do in Italy. What we planned to say was that we wanted to do some health treatments with sand, close to Trieste. And they said to us, You can get a visa for a year. It cost 6 liras, but at first, we didnt have the money for it. So, we borrowed some money and we got it. Interviewer: Before we move on, could you tell me how was it in Warsaw, how did you get around, what was happening? Herta Gerber: Warsaw was and I dont know if you can call it a life. So, it was impossible to find anything. Warsaw was terribly destroyed, especially in the parts of the ghetto because the bombing lasted one month, and during that month, the sirens there did not help us much. They also did not let us use the Polish shelters. They would not even let us come down. I remember very well that in the house where we were staying, the backyard was like a graveyard. There were last-minute graves of people killedwe could see the pilots above us. We would go down to the street holding our hands, my dad, my sister, my cousin, and my aunts. Sometimes, there was fire, and the ashes would burn our hair when we were standing against the wall because they would not let us inside. In the shelter, they would let the horses in, and the soldiers that had escaped, they were the first there. Those were the Polish heroes. The food situation was terrible, we could not find anything, not even with money. Interviewer: Were you obligated to wear the star? Herta Gerber: That happened later. They started distributing the food on the street. My aunt and I decided to go down to pick up some bread at least. The porter told the police about us, but luckily, the person in charge of controlling the lines was a soldier of the Wehrmacht, he came to us and asked me in German Sind Sie Jdin? (Are you Jewish?). If that had happened today, I would have been smarter about it and said no to be able to save myself, but at the time I was afraid and I said yes. And he said to me, We cant give food to Jews, you know, but take it today. He was more generous than that pig Polish guy. So, life was becoming impossible. If you went around on the street, you could hear how they were taking people away, especially men. Then we saw that they started to isolate some streets, there were some bricks piled up, and we started wondering what those were for. We thought that maybe they wanted to fortify the walls, so they didnt fall. Nobody realized at the time that those were for the ghetto. Anyway, one day we were able to get all our papers and we left. There werent any stations anymore in Warsaw, everything had been destroyed. In the middle of the road, there were the rails, and we got on the train there. We were the only passengers on the train. One can only imagine how scary that was. We were traveling in the direction of the Brenner, and then we arrived in Trieste. Interviewer: Could you enter Italy with your documents? Herta Gerber: Yes, we had an Italian visa. We got off the train and we asked where the Jewish community was because in order for us to leave we could only have ten Deutsche Mark. So, we asked for help in Trieste and they told us that we could sleep in the temple. It was well organized because there were already people and cot beds. We heard at the shelter that they were trying to do an illegal Aliyah, so we tried to contact our relatives in London through the Red Cross. We sent them a message saying that we were trying to get to London and if they could, send us some money. They got the message and through the Red Cross again we got the money. We paid. I dont remember how much anymore, we paid for a transport that was still illegal back then. We had to go 47 to Siracusa to board and we were like 300 people that wanted to board this train that ended up in Benghazi, you know? Interviewer: So, how long did you stay in the temple? Herta Gerber: One month. Then we tried to find a house, and we rented a small apartment, and we were waiting for the right moment to go to Israel. They made us do some physical exercises because they were saying that the ship wasnt arriving at the port, but they would put us in boats and then let us arrive at the boat swimming. Can you believe that? My mom and my dad swimming. We attempted it somehow. Interviewer: So, you left from where? Herta Gerber: Trieste. Interviewer: How did you get to Siracusa? Herta Gerber: By train. We all had visas. We were in Italy. And I think that the other people as well were traveling without problems. Interviewer: Who else was trying to board this ship in Siracusa? Herta Gerber: There were people from everywhere. From Germany, the majority from Poland. Interviewer: How much did it cost per person? Do you know? Herta Gerber: It was a lot of money, but I dont remember anymore. However, my mom was very farsighted. She left the money with one person from Bielsko that was with us. He was a good person that we knew for many years and he said, As soon as we set foot on board, we have to hand over the money. That is why my mom could get her money back. And this person that we knew gave the money back to us. That money was very useful because in Bengazi we were staying at a hotel instead of going it was a good amount of money, but I dont remember now how much. Interviewer: So, you boarded the ship in Siracusa. Did you stay a couple of days in Siracusa? Herta Gerber: No, no. As soon as we got off the train, we boarded the ship. We could not even stay. The majority of the people had just the amount of money for the trip. Interviewer: The crew of the ship was Italian? Herta Gerber: Yes, they were Italian. Interviewer: And the first shop was Benghazi? Herta Gerber: Yes, the boat brought us to Benghazi. They allowed us to get off the ship and we were all happily waiting [to continue the journey] but then June 10th arrived, and they arrested us all. We were staying at a hotel like a lot of other people when they arrested us. Actually, if I remember 48 correctly, I think that everybody went to a hotel. They brought us somewhere between Derna and Barce, in the desert. A police station in the desert. I mean, there were things around, because if there was a police station, there must be something else as well. We could not leave but once a week, we could go back to Benghazi to buy some stuff. Interviewer: Who arrested you? Herta Gerber: The Italians, because we were Jews, so they arrested us. They could not have done that with the nationalities because Nicaragua wasnt at war against Italy. Even when we were still Polish, they arrested my husband not because Poland was at war, but because he was Jewish. Interviewer: So, they caught you and how did they transfer you to the police station? Herta Gerber: With trucks. Interviewer: Did they not separate you from your mom and dad? Herta Gerber: No, no, we stayed together at the police station. And that police station was a brick house, but there werent there were some showers but only for some hours during the day. There was not much water there to begin with. So, the rest they gave us food there. Interviewer: So, you were locked there like prisoners? Herta Gerber: Yes, and outside there wasnt anything. There was only sand. Where could I have gone? Once a week we could leave, I remember there were those trucks, and once in Benghazi, there were some Jews, poor ones, and they were all in line, one with a can of anchovies, one with some lemons or some other fruits, tuna, all stuff that they would give us. And then for Friday evening, they would invite us to their house to eat. Interviewer: So, you could visit these families on Friday? Herta Gerber: Yes. We would all sit down on the floor like it was normal there. They gave us little chairs because they understood that it was hard for us; for them it wasnt. They were good people. Also, they would drink a type of liquor, you know, that was supposed to be good against mosquitos. And if you think that the smallest thing, they got trachoma. When we discovered that we started to worry because they were good people. And to live with this disease. They would give us that liquor, it was strong, and my sister, she had problems with strong things, and she started to cough. So, our friend told her, So, Lili, turn around, put your hand back and throw it away, so they think you drank it. I still remember that. They would give us couscous, it was delicious. They would cook lamb, and when I was eating it, I had to close my nose because I did not like it. I didnt like either lamb or goat. I did not like that wild taste. Anyway, they were good people, very good people. Interviewer: And then after dinner, you would go back to the police station? Herta Gerber: Yes, yes, to the police station. And we could not sleep anywhere else. Interviewer: Was there a certain time you needed to go back or how did that work? 49 Herta Gerber: No, no. We were free at the police station. We would go around, we were free, and we did not even have a reason to leave. Also, we were in a country in which we didnt speak the language. Yes, they spoke Italian, but it was everything new for us. Interviewer: Did anyone get beaten? Herta Gerber: No, no. From the side of the Italians, I can say, there was a lot of humanity. Interviewer: Did they interrogate you? Herta Gerber: No, nothing. They told us that they would bring us back to Italy. They did not mention any prison or concentration camp. They told us that Mussolini wanted us back in Italy because where we were would become a battleground. Maybe he was right because they conquered it and lost it right after that like three times with the British. So, we left BenghaziI think it was still 1940. Interviewer: Where did you all go and when was it? Herta Gerber: We arrived in Naples in September on a ship called Esperia. The Esperia wasnt a very big ship, and we went through much hardship on that ship. There were raids from the side of the British around Malta. So, I dont know which way we went through, but the sirens went off two or three times. We were without any light, standing still with people screaming, the children were screaming. Interviewer: Was it a military ship? Herta Gerber: Yes, it became part of the navy. And we were staying at the bottom of the ship. Interviewer: Were there children with you? Herta Gerber: Yes, there were also children with us . When we arrived in Naples, they brought us in groups to the prison. Outside, some people were looking at us because we looked like we were all handcuffed. People started asking about us in Naples, and they said, Jews, Jews! But they did not know what we actually were. Then they throw us oranges, chocolate, some money. Interviewer: How long was the journey? Herta Gerber: It lasted a night. For us, it felt like a very long time, you can definitely believe that. Then, we arrived all dazed because the ship would stop once in a while. They did not want to go very fast. Anyway, it was a terrible journey! Interviewer: So, you said that you were handcuffed when you were going to prison, right? They let you leave the ship and then they handcuffed you? 50 Herta Gerber: Yes, we were all tied up together. When we got off the ship, they brought us to Poggioreale. 90 They also told us that there were some of those trucks that they use still today to transport prisoners going to court, for instance. Those were pretty big busses, and they brought us slowly to the station. Interviewer: Was there someone that was translating for you? How did you understand what they told you? Herta Gerber: Some people spoke Italian and helped us understand. And that was easier for us, and also safer. You know, someone you dont know can translate what they want. But these people were also involved; they were also Jews. They escorted us to the station and then we got on the train, and we traveled for very long time. It was a long journey from Naples to Ferramonti di Tarsia. Interviewer: Did you stay in Poggioreale before travelling to Ferramonti? Herta Gerber: Yes, and it was the pinnacle because it shocked me so muchtoday, I have asthma but there, even without asthma, just seeing those windows, so it wasnt a window, it was a hole that went down and you had to look up through a slit, and that was the window. Interviewer: Did they separate you? From your parents? Herta Gerber: Yes. But not from my parents. They separated me because of my age, I was underage. The women on one side, the men on another side. And that was terrible because my mom was used to being with my dad and there it was impossible. Then, the one who was translating for us, she was really sadistic. My mom wouldnt feel well during the night and to get anything like a tranquilizer we had to scream. I did not even know about this tranquilizer. I just saw my mom like that. Interviewer: How many were in your cell? Did they put you in cells? Herta Gerber: Yes, in the cells. We were four to a cell. I was with the young people, my mom, my sister, and someone else but I dont remember who she was. So, I was with them, so three people. And my dad was on the other side. Interviewer: Where were you? Herta Gerber: I was upstairs with other children. Then I asked if I could rejoin my family and they were like, no, but if you do so, you will give up the food. They gave herrings to the children in the morning. Interviewer: So, you were the oldest among those children? Herta Gerber: Yes. But there werent only Jewish children, there were also other convicted children. 90 Poggio Reale is a neighborhood of Naples in southern Italy. 51 Interviewer: So, the Jewish children were together with the other children? Herta Gerber: Yes, and it wasnt a cell. It was a room because we were all underage. Interviewer: So, it was like a nursery? Herta Gerber: Yes, like a nursery. Interviewer: How many were there of you? Herta Gerber: Twenty, maybe. But not all the children were from our group. There were young people too, some of them older, some of them underage, but there werent many. And why were they keeping us there? Because Ferramontis barracks werent ready yet. They could not find another way to keep the people if not in that prison. For the air. Interviewer: What did they tell all of you? Did they keep you there without saying anything? Herta Gerber: They told us that we had to go back to Germany. They told us that. But they had another plan. One day they told us, We are leaving today and to where? To a concentration camp. Where? They said it was in Calabria. So, they loaded us on a track and brought us to the station. Interviewer: Was that in the morning or the evening? Herta Gerber: I think it was in the morning. Interviewer: So, people could see you? Herta Gerber: Yes, of course, and they also asked why we were all handcuffed? And there too, some people brought oranges, I will always remember that. And from their faces you could see that they were afraid because they were seeing women and children. The journey took a while. It was a little train. And when we arrived at the camp, there wasnt a station in the Ferramonti concentration camp, the station was called Ferramonti-Scalo, and the train stopped there. The director of the camp arrived in his car. I remember the car did not have a roof, and he would carry the women. The rest would go with the tracks. He was nice to us. He was an ex-superintendent from Salerno who became the director. I cant remember his name. He was nice, a good person. In general, everyone was good to us. Interviewer: Was he from the military, from the carabinieri or the police? 91 Herta Gerber: From the police. All of them. There was one among them, his name was Formica, this I remember. He went with my father in-law. Back then he wasnt yet my father in-law, to Milan by train because he had a 3-or-4-day permit to go visit. the mother and the 3 sisters were free in Milan. They took only him and his dad, can you believe that? This man received presents from the family because my mother in-law was trying to become a friend of him, but he was a good guy. He behaved himself humanly. 91 The Carabinieri are the national gendarmerie of Italy who carry out domestic policing duties. 52 Interviewer: Do you remember the date when you arrived in Ferramonti? Herta Gerber: It must have been in September or October, around that time. Interviewer: So, it was around your birthday, you were turning 17 years old? Herta Gerber: Yes, my birthday was on September 23rd, but it wasnt an important thing back then. It was more important to know what was about to happen to us. When we arrived in Ferramonti a new world opened to us, you know? Of course, with some limitations. Interviewer: Could you describe it to me? Describe Ferramonti, how was it? What did you think when you arrived? What did you see? Herta Gerber: A stretch of land and behind it there were some hills. It was so quiet, and coming from a place such as a prison, full of people. It was also relaxing for your nerves. When they assigned us our little apartment, there were two little rooms, one for my parents, a little kitchen, and outside there were the shared toilets. Interviewer: So, you were able to be reunited with your family, right? With your dad and your sister. Herta Gerber: Yes. Interviewer: Did other people also get these family apartments? Herta Gerber: Yes, all the families did. Interviewer: Was the apartment made with brick walls or with wood? You called them barracks. Herta Gerber: No, they werent made with brick walls. They were made of concrete. They were white and [we thought them] clean. Because after what we went through in prison, with lice and bedbugs, it was brutal. Interviewer: Did you arrive with your clothes? Did you still have your dress? Herta Gerber: Yes, we had our stuff or what was remaining because the train, departing from Warsaw, we had 18 bags. We had all that stuff. When we arrived at the border with the Netherlands, they refused us, the Dutch people. But those were people at the border, so they were more German than Dutch. That is why it was written as nicht zulassen, dont trespass. And we had the tickets until London, we bought them, and it was supposed to be only a transit. Anyway, these bags were also sent to Rotterdam, and they stayed there together. We paid so much for the storage space, so many pounds, for 4 years. Schenker is not a joke. 92 Anyway, even from the affectional value, we had some important things. Interviewer: So, you lost all your 17 bags? Schenker is a division of German rail operator Deutsche Bahn AG that provides shipping and logistics services. 92 53 Herta Gerber: No, no. Those were sent away. They left us on the train. I remember what happened to my cousin before crossing the border between Germany and the Netherlands. They told him jump you bastard Jew so that we can find gold coins. But, you can imagine, we did not have anything with us. The Germans even took my moms wedding ring away from her hand. You mentioned our bags, we had the necessities for every day. Interviewer: Did they give you some clothes there? How did they welcome you? Did they give you this family barracks, did they also give you some clothes, some blankets? Herta Gerber: Oh well, we had some clothes with us because in Benghazi we bought some stuff before getting arrested. We had the money. We did not have much but to get changed, it was enough. Interviewer: What did they do in Ferramonti? Did they register your names? Did they interrogate you? Herta Gerber: Yes, there were all our papers, our vaccines record against malaria, that did not work very well. We had a salary of 3 lire per day, and the men 5, the wives 2. Look, so much money. 93 It was enough to do grocery shopping, to buy food. Interviewer: Tell me how it was organized. You had your own kitchen then? Herta Gerber: Yes, each one of us had our own. Interviewer: And your mom did the cooking? Herta Gerber: Yes, she did. She would go grocery shopping to buy food in a shop there. I remember that there was an engineer working there that was in charge of accounting as well. He told me, If you (formal) I mean you (informal) because I was still a child, if you need anything. I remember, his name was Tassani, the director there, I will get you what you need. 94 He was very nice. Interviewer: And this shop, did you work there? Herta Gerber: Yes, I did, at the register. Interviewer: Who decided which jobs would one do in the camp? Herta Gerber: You would ask for it. We were the first to arrive, you know. So, we had more possibilities. We were almost 2,000 or 3,000 people, 2,500 you know? The shop had a great selection of food. My sister worked at the tobacco shop, and her partner So, she worked in the part that did She is being sarcastic here. Italian distinguishes between an informal you (tu), usually used among friends and family, and a formal you (Lei), used in formal contexts. 93 94 54 not sell food. So, in a haberdashery. They sold soap and stuff like that. He was a doctor, and he would sell tobacco, the shop was divided into two parts. Interviewer: So, you were also in charge of selling stuff. Herta Gerber: Yes, that is correct. Interviewer: Where did the stuff to sell come from? Herta Gerber: It arrived from the towns that were close to the camp. The dealers would come in, we got bread every day. Interviewer: Did you buy the stuff with the money you got daily? Herta Gerber: Yes, with that money. Interviewer: Was that enough? Herta Gerber: Oh well, not always. It depended on what you ate. If you had bread and onions, yes. But we had some money on the side. And I worked, so I had a salary. I dont remember anymore how much it was. Interviewer: The jobs were all paid? Herta Gerber: Yes, they were. Interviewer: Was your sister at the haberdashery paid too? Herta Gerber: Yes, my sister too. Interviewer: Who was in charge of paying the salaries? Herta Gerber: The administration. There were administration offices in the camp. There was a secretary, a director, and an engineer what was his name? He was a good person. He was the one who designed the camp, he built it, and then he controlled the camp overall. Interviewer: So, you said that there were barracks for families and then barracks for men only, right? Herta Gerber: For men only, yes. Interviewer: And the toilettes were outside? Herta Gerber: Yes, for everybody. Some barracks had one toilet. And for us that lived in the family area, there were some houses with the toilets. Interviewer: Was there water? 55 Herta Gerber: Yes, there was water, but we had water in the house too to shower. Interviewer: And power? Herta Gerber: Yes, we had power too. Interviewer: Was the camp surrounded by barbed wire? Herta Gerber: Yes, there was a fence, but it wasnt an electric fence. There were some guards that would call out our names, they would come to the barracks, so we did not have to go out. They would count us to see if everybody was there. Interviewer: And this would happen every morning? Herta Gerber: Yes, they did it in the morning, and they would also come inside our house. We would leave the door open. It was a friendly relationship. The people from the black market would come too, they would bring eggs inside the camp through the fence. And I remember that my father in-law would go with a little trolley to bring watermelons. He got diarrhea once because of all that watermelon. And sometimes we went bathing because there was a river there. Interviewer: Could you go outside? Herta Gerber: Yes, we could go outside with an administrator. They would come with the people that wanted to swim in the river too. We could hear the bombing sometimes. We were at the opposite side of Crotone, and Crotone was bombed all the time because it had a port. The sky would turn red in Ferramonti and you could see it on the other side. Interviewer: Could you move freely inside the camp? Herta Gerber: Yes, we could. They even built a soccer field, and they would play some matches. So, the Polish Jews would play against the German Jews. My husband was one of the few who had football shoes because he used to play soccer in Budapest as a reserve for the national team. Interviewer: Tell me when you met him because you are already talking about your husband, but I did not hear that story about when you met this beautiful guy. You met him in Ferramonti, right? Herta Gerber: Oh yes, I met him in Ferramonti. As soon as we came in, on the first day, he was playing table tennis. They had put a table between two trees, and he was playing table tennis. Interviewer: He was in the camp already for a couple of days, right? Herta Gerber: Yes. So, he was there he was a month in San Vittore. He was already there, he had been already in another confine, in Campagna di Eboli, and from there, he was sent to Ferramonti. 95 Confino was the confinement on a small island or in a small village usually in southern Italy that the fascist regime used as a punishment for the opponents of the regime, Jews, and homosexuals. 95 56 Interviewer: So, you met him on your first day at the camp? Herta Gerber: Yes, on the first day. His uncle, who was in our group, was saying that he was sent to a camp and if he was in this camp, he had to see him. So, he introduced me to him. Interviewer: So, there were Jews from different parts? Herta Gerber: Yes, Polish, Germans, some French, but not many. The majority were Polish and Czechoslovaks, and Hungarian Jews. In the transport that got my husband there, there were people who recently graduated from medical school. They all got there, and my brother-in-law was there too. He is not with us anymore. He wasnt able to take the state exam while he was there; he took it after the war. Interviewer: So, what were you supposed to do all day? Herta Gerber: We were free to do whatever. There were schools, kindergartens, there was an infirmary, there was a theater; they had concerts. We lived a life that was very culturally active. Interviewer: I heard there was a temple there too. Herta Gerber: Yes, there was. My sister got married there. Interviewer: Oh, there was a rabbi there? Herta Gerber: Yes, there was, Rabbi Adler. But the strange thing was that this rabbi, after marrying my sister, after a while he said, Im not authorized, maybe your marriage is not valid because Im not fully authorized. My sister was so sad, she said to me, What should I do now? and I said to her, You will just get married again with another rabbi. She had all the papers anyway. Interviewer: And this fist wedding, did your sister get a family barrack or what happened with her and her husband? Herta Gerber: Yes, yes. He came to stay with us. They put him with us. Interviewer: I see. Is there anything else you remember that you would like to tell me about? Herta Gerber: Oh, well. Life there became slowly normal. We were sort of ok with that, we didnt feel like prisoners anymore. We didnt stay that much there to begin with, a total of 18 months. We also asked to be moved up north to stay in confino. Interviewer: Alright, could you explain this to me? So, you asked to be transferred to where? Herta Gerber: Only married people. That means people that had family members. And this included my husband because he had his father with him. He wasnt alone. Since he wanted to go north to stay close to his mother, we asked to be transferred close to Bergamo. Interviewer: So, you chose Bergamo? 57 Herta Gerber: Yes, we did. Also, the family of my husband was there, in Milan. And Milan and Bergamo arent very far. So, we moved north Interviewer: When did you leave Ferramonti? Herta Gerber: In the spring. Interviewer: Was it hard to get permission to be transferred? Herta Gerber: Not at all, it was something fairly common. They proposed it, so, I think they needed to have fewer people in there too since we were constantly getting new people. And so, we arrived at Bergamo. He had to go around a little bit. Interviewer: Which restrictions did you have? Did you have to stay in a particular place? Herta Gerber: No, you had to rent a place and once a week, on Sunday, you had to go and show up at the carabinieri station. This was the only obligation that we had. They would give us money there too. And that was it. We couldnt go far without permission, outside of Bergamo. Interviewer: Did you have your ids? Herta Gerber: Yes, we did. We had our ids. We were living well. Interviewer: How did you settle in Bergamo? Did you find a place? Herta Gerber: Yes, we did. We found a place. We couldnt work though. My brother-in-law was working illegally as a veterinarian. He would go to the farmers, he was very friendly, and a lot of farmers got to know him. So, they asked him why dont you come to check on our animals? They paid him with eggs, milk, a chicken sometimes. Interviewer: Did you listen to the radio? Did you get any news about the war? Herta Gerber: Yes. While there, we managed to have a very nice group of friends, because the people there were curious about us and wanted to get to know us. And we ended up meeting a lot of families that were on our side, that means against our oppressors. We would listen to London Radio. The priest was a very good person, you know? That priest, Giuseppe Bravi, he was a very a real priest from the farmland, not like a priest from a big city that wants luxury. This priest had very old shoes on. Back then, they didnt get any stipend. His sister would provide for him. He would preach in the morning to a big group of very conservative women who were all about the church and he would say to them, It doesnt make any sense that you come here to pray if you dont do any good deeds. I have to feed five people. Dont ask me who they are, but if you can bring something, I would really appreciate that. For instance, for Pesah... he knew when we had Pesah because of his books he told us, Look, now you cant eat bread anymore. It was very moving. He remained our friend even during the raids, he helped us go hide in the mountains, in the barns. And then, when we came back, we would give him something. When my brother-in-law would come, he would bring him stuff, he would buy stuff for him to help him out. But all the people from there helped us. That is the reason why we decided to stay in Italy. My husband, with his job, he 58 could have gone everywhere. But money isnt everything. To have nice and caring people around that are willing to help you is also important. I think things have changed though today. Interviewer: Where did you live in Bergamo? Herta Gerber: In Crusone. 96 It is a very beautiful town. Then my husband got transferred to Gandino. 97 And that was even better because the people there were even more helpful. We still have a very good relationship with the people that are still there. A lot of them have passed away. Interviewer: What happened in July with the fall of the fascist regime? Herta Gerber: Oh well, when that happened so, you are talking about the time before? You are talking about Badoglio, 98 right? Interviewer: Yes. Herta Gerber: People started saying that the war had ended. My dad kept saying that he wouldnt leave his hiding place because he was scared. Then a very sad period started. They told us to get all our money. Interviewer: Oh yeah, because you were still getting the money, right? Herta Gerber: Yes, we were. So, he told us, Take your money now because I dont know if you will be able to pick it up later. It is better that you leave and go hide in the mountains. They have already asked to see the list of all the Jews. Then, we went to our friends, yeah, in the meanwhile, we became very close friends. We went to Rovetta, where there was that priest, and we lived in a storage room with furniture in it, left by an emigrant that left for Switzerland. This was in the middle of the town, on a hard floor. And we lived there until 1945 because it was hard to go up in the mountains with our parents that couldnt speak Italian. We younger people could have done that. That situation was very sad. My dad never went out, my mom too. I would go around in the evening. I had a bike, it was a present from my husband a Bianchi 99 bike, it was heavy, but it was a good one. I would ride back to Crusone, to our former landlord, who was the president of the society of San Vincent, 100 and she would receive the ration cards because we didnt have them anymore. And with these cards, we were able to go grocery shopping. I would give the list to someone and they would buy the stuff. Once, when I was going there, the carabinieri stopped me. I had a backpack with me. So, one of them could write, the other could read... 101 In the end, one was carrying my bike, and the other was talking to me. Then I told them, Now I have to go because my boyfriend is waiting for me. Then they looked at me and said, Your boyfriend is very young then, Crusone is a town in the province of Bergamo. Gandino is a town in the province of Bergamo. 98 Marshal Pietro Badoglio was an Italian general during both World Wars and the first viceroy of Italian East Africa. With the fall of the Fascist regime in Italy, he became prime minister of Italy. 99 Bianchi is an Italian bicycle company and the worlds oldest bicycle manufacturing company. 100 The Society of St Vincent de Paul is an international voluntary organization in the Catholic Church, founded in 1833 for the sanctification of its members by personal service of the poor. 101 She is trying here to tell a joke about the Carabinieri. 96 97 59 and I replied, Oh yes, and I left. They wouldnt do me any harm because there were good people but that was during the curfew. But I went out anyway. I wore a black shawl like the farmers. I had a fake ID with a fake name Baradelli. Giulia Baradelli. I was able to give a fake ID to my husband too. A friend of my brother in-law was a partisan, and they were able to get fake documents. Giovanni Battista Nodari, who was way older than my husband. Interviewer: And what happened after September 8, 1943 102? Herta Gerber: After September 8, 1943, things went bad because they did raids more often. The SS were all around. Interviewer: Who gave you the information? The priest? Herta Gerber: Yes, the priest. And there were also some farmers with the radio that tried to get the news. It was bad because we knew that the people could turn us in people were also instructed to hand over every Jew for 10,000 liras, and that was a lot back then. Once a marshal came with a pickup truck to get us, but they did not find us. Then, he went to the priest asking, You dont know where these people are? and the priest replied, Oh, they left, they went to Switzerland, they crossed the border and left. We were able to escape, and that happened on other occasions too. We had to change locations multiple times because the raids in the mountains were awful. My mom wasnt feeling well in the hay, and there were rats, there werent that bad, but those were rats anyway. Interviewer: So, you changed locations often? Herta Gerber: Yes, we did. In the morning, we ate chestnuts. My dad would cut and cook them. It looked like I wouldnt say a picnic, but more like military training. The time wouldnt go fast enough. And the war came closer and closer. It was getting more and more dangerous because there were so many fascists close to where we were hiding. We also feared that people would report us. Not everyone is a good person. But on liberation day Interviewer: Oh, tell me about it Herta Gerber: That morning, I was going to the mountains to buy milk with a friend who knew the way there. When I came back, they said, The war has ended! We ran home and my dad refused to go out for two days until the priest arrived and told him. Look, it has ended, lets go and see Mussolini hanging! and he told us Come with me! He was a captain of the Bersaglieri. 103 He took a cart with a horse and we went to Milan my sister, the priest, and myself. When we arrived at Loreto Square, 104 it was incredible. I saw a woman spitting on him, she had lost two sons. There were people screaming. It was terrible, I was disgusted in the sense that it wasnt humane anymore. On 8 September 1943, the Badoglio Proclamation by Marshal Pietro Badoglio, Italian head of government, announced that the Cassibile armistice between Italy and the Allies signed on September 3 had come into force. 103 The Bersaglieri are a special unit of the Italian Army infantry corps. 104 Piazzale Loreto is a major town square in Milan, Italy. The body of Mussolini was taken to Milan and left in the Piazzale Loreto for a large angry crowd to insult and physically abuse. 102 60 But those people suffered terrible things and I dont know how they managed to survive. It was raining that day. We went back and the priest said, Im happy. I saw the end of that criminal. He wasnt a communist or a partisan, but he led a patrol that killed sixteen members from the Muti group. 105 Those were fascist, very young boys, fifteen, sixteen years old. They killed them in the cemetery in Rovetta, we could hear the shots from our place. And the priest said that it was the right thing to do because they hanged so many people in the square. They would leave the bodies hanging for three days so that people could watch. They committed relentless slaughter, burned down entire towns, they cut the hair of those women who collaborated with the Germans. My husband sold two wigs to two women that got their hair cut. They asked him because he had relatives in Milan. He didnt know it was for that. They asked him to bring wigs used in the theater and he had some with curls. So, stuff like that, and when you talk about them, it seems like you are telling jokes. Interviewer: After the liberation, did you still stay in the little town, or what did you do? Herta Gerber: Well, after the liberation, we tried to go to Milan. My fianc and I wanted to see if we could get married and if he could start working. And we wanted to have a home, that was a big deal. Where else could I have gone? There was an office in the square what was its name? Do you know where Case Rotte street is at? In the city center, Scala Square. There is also the native home of oh, he was a writer... there is a restaurant there. Interviewer: Manzoni? 106 Herta Gerber: Yes, exactly! In that house, there was the office for those houses that had been seized. We went there. Those houses were now free, so we could have one of them. There was an accountant, Basola, he was also from the community, he said to us, Wait, I will try to help you and give you an address. Close to the main station, in Vivaldi Street we were always among musicians, there was a little villa of an ex-fascist of a fascist, he was in a concentration camp. The accountant told us, I could give you that one. And we said, Ok, but if there is stuff inside? And he replied, You take the stuff down in the basement, and you put your stuff there. I didnt have any furniture, so I said ok. We did that. Until we get a new house, we can use the bedroom. I gathered some Jews to get a full house. I went on Unione Street. Interviewer: What was there on Unione Street? Herta Gerber: I got married there. There was the Scalchi building, back then it was not really like a police station, but the temple was there, where I got married. There was a nurse and the infirmary. Some years ago, the nurse who was in charge of everything died. There were also a lot of people that had news, you could get there to get information. There was a tobacco market, the black market. Then I gathered a group of people. There was this family, the Weiss family, they had two children. I asked them, Do you want to come and live with us? It was for free. It was just to fill the house. But then, how did they pay me back but this is another story. There was also a boy who was able to survive Auschwitz with his brother. He saved his brother and did all he could to keep him alive. The autonomous Legion Ettore Muti was a fascist military group which was active in the area of Milan and Cuneo. 106 Alessandro Manzoni is one of the most famous Italian writers of the 19th century. 105 61 He died here because of the after-effects. His name was Bernhard, I dont remember his last name anymore. Interviewer: What about your parents? Where were they? Herta Gerber: They were still in Crusone. We were in Milan without a house, and I would go back and forth. When I gathered enough people for the house because I didnt want to have a villa and live like a princess in there. The house had a beautiful garden with a lot of fruit. In the nights, people would come inside and steal the persimmons, and I had to pay the owners. We became friends with them, they were fascists. I explained to them that we didnt take anything, we went in because we didnt have a house. We became friends. Interviewer: You got married in December, right? Herta Gerber: Yes, yes, I did. And in the meantime, I would go back and forth to Crusone to see my parents. Interviewer: Who married you? Herta Gerber: Friedenthal. My sister left, and my parents did Aliyah too. They went first to Cinecitt, 107 because from there, there were also the transportations to Israel. They lived for one year in a place made of tin until the stuff from London arrived. The furniture and money. Then they bought a little villa, and they started living like they were used to. Interviewer: And you decided to stay in Milan with your husband? Herta Gerber: Yes, I stayed in Milan with my husband. He is a fur trader. It was hard at the beginning because there wasnt any material, so he had to work with very low-quality items. The goats were in terrible condition because of the war. They were barely standing. We bought a car and I learned how to sew. We had to start our life again. Before the war, he imported the goods. He was a supplier and fur trader. It was a tradition in his family, his dad, his granddad. He started to go back to London and in the meanwhile, we rented a house in Piave Avenue, because the fascists came back and wanted their houses back. I wasnt happy about it because of the area. It was the area of the railway workers. They got together and built houses. And I wanted to be able to go to the city center. So, we first rented an apartment on Piave Avenue where my husband kept the goods. Interviewer: What else would you like to talk about from that time? Herta Gerber: When our daughter was born, life was good again. They say that every child brings luck. I regret the fact that I did not have any other children after that. Those were hard times when the war ended, there wasnt much of anything and you could not do much, you are limited. Italy was ruined. Anyway, Im happy and my daughter did better than me, she had two children. Cinecitt Studios is a large film studio in Rome. With an area of 400,000 square meters, it is the largest film studio in Europe, and is considered the hub of Italian cinema. The studios were constructed during the Fascist era as part of a plan to revive the Italian film industry 107 62 Interviewer: What is the name of your daughter? Herta Gerber: Barbara. Interviewer: After the war, did you join the Jewish community again, did you go to the temple? Herta Gerber: Yes, we did. Interviewer: Did your daughter go the Jewish school? Herta Gerber: Yes, until graduation. She also kept out Jewish traditions in her family. Interviewer: When did your daughter get married? Herta Gerber: I dont remember. So, Isabel was born in 1974, so she got married in 1970... 1971, I dont remember. She married a very good man. We love him like he would be our son. Steven Sassoon, he comes from a good Jewish family. Interviewer: Then the grandchildren were born Herta Gerber: Yes, the grandchildren were born. Isabel in 1974, and Paul in 1976. Isabel is in Israel. She came to visit for Easter, to spend time with us. She went to school, she is a good girl, she has already graduated. Paul studies in London. He is also a good man. They mean so much to us. I hope God will keep them safe and spare them any difficulties, not even mentioning what we have gone through. I would like to give them not a warning, but a piece of advice. To try to stay close to the Jewish people and to not trust much the events that could happen because what happened to us was completely unexpected. We did not see any signs. I hope they will have a happy life without these difficulties. Interviewer: Thank you. 63 Prisoner No. 9,653: Eugene Debs on capitalism, incarceration, and solidarity 108 Peter Cole Eugene Debs (18551926) might be the most important, influential, and well-known anti-capitalist in U.S. History. Hes best known as a co-founder of the Socialist Party of America (SPA) and its four-time presidential candidate. Before that, he led the American Railway Union (ARU) which, in solidarity with striking workers of a railroad company, pulled off perhaps the greatest work stoppage of the late nineteenth century. He also helped found the Industrial Workers of the World (IWW), a revolutionary union whose members are known as Wobblies. In addition to being a respected labor and political leader, and a brilliant speaker, late in life he became a ferocious critic of prisons based upon his own experiences with incarceration. He had served six months in prison for his role in leading the Pullman boycott and strike in 1894. Then, in 1918, he was sentenced to ten years in prison for his outspoken opposition to U.S. involvement in World War I. His criticism of what now is called the prison-industrial complex was rooted in his personal experience which, itself, was part of his larger critique of capitalism. This essay was adapted from my keynote presentation at the conference of the Eugene V. Debs Foundation, While There is a Soul in Prison, I Am Not Free: The History of Solidarity in Social and Economic Justice, in April 2021. Thanks to Wes Bishop, the Eugene V. Debs Foundation, the Cunningham Memorial Library, and the Indiana State University Department of History. 108 64 This essay contends that his embrace of working-class notions of solidarity and class struggle, along with his hopes and dreams for socialism, were based in his experiences as a worker, unionist, and prisoner. While not considered a prison abolitionist by most, it is instructive to locate Debs in that movement. He believed that capitalism was the root cause of the problems with mass incarceration: Capitalism and crime have become almost synonymous. 109 Hence, prisons were emblematic of the broader issue that capitalism created inequality and poverty that could and should be eradicated with socialism. In recent years, Debs has been experiencing something of a renaissance. Obviously, Debs coming into vogue is due to the renewed interest in socialism as evidenced, for instance, by the explosive growth of the Democratic Socialists of America (DSA) in the mid-2010s and early 2020s. A brief investigation of Debss life offers much about labor and political organizing as well as the movement against mass incarceration. The life of Eugene Victor Debs, best described by his biographer Nick Salvatore, very much defined American life from the mid-19th into the early 20th twentieth centuries. No doubt his popularity was due, in part, to the fact so many others could relate to himi.e., he was of the people. Debs was born in 1855, shortly before the Civil War, to immigrants from the Alsace region of France. He was born and raised in Terre Haute, Indiana, on the states western edge and along the eastern banks of the Wabash River, just across from Illinois. In the 1850s, Terre Haute still was something of a frontier town. It also was something of a boom townbenefiting from its location on the Wabash but also thanks to the multiple, important railroad lines that passed through the region. 109 Debs, Walls and Bars, 171. 65 At fourteen, Debs ended his formal schooling and found work on the railroads. He first cleaned grease from the trucks (or wheels), a dirty and dangerous if vital job. Then he became a painter and car cleaner in railroad shops; later, and for many decades, he kept a small tool he had used to scrape paintdisplayed on a wall of his house. After cleaning and painting trains, he worked as a fireman (or stoker) for a few years; stokers shoveled coal into the furnace that powered the steam-driven engines that transformed the US into the worlds mightiest industrial country in the world. Stoking was hard, hot, and dangerous. Although he worked on the railroads for only five or six years, Debss experiences were quite formative to his worldview. He said as much at his federal trial, in 1918: At 14, I went to work in a railroad shop. At 16, I was firing a freight engine on a railroad. 110 By the age of twenty, he no longer worked on the railways, settling back in his hometown. Instead, he worked a as a clerk in a dry good store. Although comfortable, he wanted more, so he ran for and was elected to several political offices, at the local and state levels, as a Democrat. However, he quickly became disillusioned with mainstream electoral politics. Instead, he found his lifes calling as the editor of his unions newspaper, Firemens Magazine, and then as grand secretary-treasurer of the Brotherhood of Locomotive Firemen. In 1885 he married Katherine Kate Metzel, also from the same Indiana town. While Kate maintained the house in Terre Haute for the rest of her life, Debs traveled constantly and for many decades. They never had children and she rarely traveled with her husband. Arguably, he was closer with his younger brother Theodore, who was a constant companion and confidante. 110 Debs, Debs and the War, 40. 66 In 1893, Debs played a pivotal role in forming the ARU, which elected him as its first president. The ARU was founded as an industrial union, in stark contrast to the typical railroad craft unions, including Debs old one. Called brotherhoods, the railroad industrys craft unions were conservative, meaning they solely focused on the material interests of members and nothing more also nicknamed bread-and-butter or pure-and-simple unionism. By contrast, the ARU was industry wide, meaning any worker in any craft in the industry could belong. Debs and other founders of the ARU were influenced by the Knights of Labor, the first powerful union to emerge, in the mid-1880s, as a national force. Simply put, industrial unionists believed workers were far weaker when divided into different craft unions. They were well aware railroads were the largest, wealthiest, most powerful corporations the country had ever seen and believed workers only could stand up to them by uniting everyone in the industry. After all, the brotherhoods clearly had failed to amass sufficient power to challenge the railroads. Industrial unionists hoped to counter the wealth and political influence of corporations with superior numbers and solidarity. Debs also was mindful of the pervasive nature of white supremacy deeply dividing the U.S. working class which was, and remains, far more diverse than the middle and upper classes. In the Gilded Age, Debs was quite unusual among white unionists in loudly advocating for equality for African Americans, including in unions. At the ARU founding convention, Debs spoke in favor of opening membership to Black railroaders; however, the majority rejected this proposal. This vote was indicative of the racist line that most working-class white Americans refused to cross. While Debs had not embraced Socialism as a philosophy yet, he already embraced a commonsense notion of solidarity that is socialisms foundation. 67 Despite this setback, within months the ARU demonstrated real promise. The ARU quickly had become the countrys largest union, with over 100,000 members. In April 1894, the ARU defeated the powerful Great Northern Railway in a strike that reverberated across the land. The following month, the ARUwith Debs at the helmundertook the largest, arguably most important strike of the era. The previous year, the worst depression of the still-young American industrial economy had begun. Nicknamed the Panic of 1893 though it lasted five years, millions of workers were laid off by businesses in a desperate attempt to avoid going bankrupt though many still did. Just south of Chicago, the Pullman Palace Car Company, the countrys leading manufacturer of dining and sleeper railroad cars, fired many workers while the rest saw their wages slashed. Worse, their rent was not reduced; since the Pullman company was both an employer of and landlord for many workers in the town of Pullman, cutting wages without cutting rent was a double blow few could handle. Many Pullman workers belonged to the ARU, and this local declared a strike in May 1894. In solidarity, albeit with trepidation, Debs and the entire ARU voted to boycott all railroad lines still moving Pullman carsnationwide. That is, the ARU called for a boycott of every railroad line that used Pullman cars, whether in Maine, New Mexico, or anywhere else. Technically this action was not a strike because railroad workers continued working (other) railroad cars. However, since Pullman cars were so numerous, the effect of the boycott was to snarl traffic across the country and greatly impair commerce across the nation. The boycott proved incredibly effective, particularly in Chicago, the industrial and railroad hub of the country. Debs compared this boycott to the Christ-like virtue of sympathythe hope of civilization and supreme glory of mankind.111 111 Salvatore, Eugene V. Debs, 137. 68 What had started as a strike in the Chicago area became a national one in which hundreds of thousands of railroad workersnot even all in the ARUrespected this boycott. In so doing, the ARU demonstrated incredible power and the effectiveness of the industrial union model and working-class solidarity. As the Pullman boycott shut down the most important city in the country and slowed traffic nationwide, employers and those sympatheticincluding the middle and upper classes, mainstream media, and political establishmentcriticized Debs. A New York Times editorial called Debs a lawbreaker at large, an enemy of the human race. 112 Debs and his supporters, of course, thought quite differently. Debs described this struggle as a contest between the producing classes and the money power. The Pullman boycott carried on for more than two months, largely peacefully, until the General Managers Association, a Chicago-based organization of several dozen railroad corporations, secured the active support of the federal government. U.S. Attorney General Richard Olney, who previously had many railroads as clients and still received a huge retainer from one, deployed the U.S. Department of Justice to defeat the ARU. Olney suggested that railroad companies put U.S. mail onto Pullman cars. That way, if railroad workers refused to move trains with Pullman cars attached, they interfered with the delivery of the mail; in other words, boycotters unknowingly and unintentionally were tricked into committing a federal crime. Quickly, a federal judge issued an injunction ordering railroad workers to cease interfering with the mail. Since the ARU refused to call off its boycott, President Grover Cleveland ordered tens of thousands of U.S. soldiers to enforce this injunction. Although this boycott had been peaceful up 112 New York Times, July 9, 1894, 4. 69 to that point, once National Guard troops were involvedincluding in Illinois, where the governor opposed deploymentclashes quickly broke out between strikers and their sympathizers against the military. In more than a score of states, dozens were killed and hundreds injured. Soon enough, the railroads started running again, with Pullman cars. Once the president, attorney general, federal judiciary, and military sided the employers, the ARU boycott was broken. Debs and seven other ARU leaders also were found guilty of violating the federal injunction and sentenced to prison, in Debss case for six months. Debss experience in Woodstock proved pivotal in his life and, indeed, the entire country. He and the other ARU members served their time in prison in tiny Woodstock, Illinois, about fifty miles northwest of Chicago. Just like later political prisoners in Northern Ireland, Palestine, and South Africa, they chose to educate themselves. They formed the grandly named Co-Operative Colony of Liberty Jail, reading books on economics and history, to prepare for the next chapter in the working-class struggle. The Woodstock jailer allowed many visitors, including several who helped Debs convert to the cause of socialism. Many accounts give the credit to German-born, Milwaukee-based socialist Victor Berger with Debss conversion experience. However, Scottish union leader and Labour Party leader Keir Hardie also visited Debs and urged him to embrace socialism. Unlike Berger, Hardie came from a much more humble, working-class background. Due to the intense poverty of his family, Hardie had gone down into the coal mines as a ten-year-old. Hardie joined the coal miners union and, later was a founding member of the British Labour Party. Labours first Member of Parliament, Hardie happened to visit the United States in 1895. During his severalmonth tour, Hardie spoke in Chicago on the second U.S. Labor Day. Hardie then visited Debs who had deeply impressed the Scottish unionist and socialist. 70 In the most widely circulated telling of Debss conversion story, Berger brought some English translations of writings by Karl Kautsky, a Czech Austrian writer very well known as an interpreter of Karl Marxs writings. However, Hardie also left some writings for Debs, who already was developing such a worldview. In prison Debs had plenty of time to think about how the Pullman boycott was incredibly effective until the U.S. government put its fingers on the scales and basically defeated the strike. Therefore, Debs became far open to more radical politics. As Debs later wrote: The writings of Kautsky were so clear and conclusive that I readily grasped not only his argument but also caught the spirit of his socialist utterance and I thank him and all who helped me out of darkness into light. 113 Right after completing his six-month sentence, Debs walked out of Woodstock jail only to be greeted by a huge crowd. He then took a train to Chicago where, despite heavy rains, a crowd of reportedly many tens of thousands of supporters thronged the station. Soon after disembarking, Debs gave a speech and declared: Manifestly the spirit of 76 still survives. The fires of liberty and noble aspirations are not yet extinguished. I greet you tonight as lovers of liberty and as despisers of despotism. I comprehend the significance of this demonstration and appreciate the honor that makes it possible for me to be your guest on such an occasion. The vindication and glorification of American principles of government, as proclaimed to this world in the Declaration of Independence, is the high purpose of this convocation. 113 Eugene V. Debs, How I Became a Socialist, New York Comrade, April 1902. 71 Debs continued, lambasting elected leaders as men with heads as small as chipmunks and pockets as big as balloons who occupied the most sacred public offices. 114 Debss criticism of both main political galvanized people and further transformed Debs into an immensely popular public figure. In the late 1890s Debs continued to figure out his politics. In the words of biographer Salvatore, The Debs who emerged from jail was not the same man who had gone in... a new idea, that of socialism, was beginning to take hold of him. 115 However, the Socialist Party did not yet exist, though other, very small such parties did, including the Social Democratic Party of America. Meanwhile, Debss old union, the ARU continued endorsing quite socialistic policies, including government ownership of the railroads. In an open letter for the ARU newspaper, the Chicago Railway Times, Debs declared, We have been cursed with the reign of gold long enough. Money constitutes no proper basis of civilization. The time has come to regenerate society. We are on the eve of universal change. 116 Just a few years later, in 1900, Debs helped found the Socialist Party of America (SPA) and became its standard bearer for the next quarter century. In the view of SPA supporters, the two main political parties in the United States were both committed to capitalism as demonstrated through policies that ignored the plight of most American workers and farmersrhetoric notwithstanding. Hence, Debs and other socialists believed a radical alternative was needed. Notably, the idea that Americans could create a new party that, in the not-so-distant future could gain power, did not sound nearly as far-fetched as it does to Americans in the 2020s. After all, in Debs, Liberty: Speech at Battery D, Chicago, 1895, in Debs: His Life, Writings and Speeches, 337 344. 114 115 Salvatore, Eugene V. Debs, 149. 116 Quoted in Salvatore, Eugene V. Debs, 162. 72 the 1850sjust two generations priorthe Republican Party had been born, elected a president in their second election attempt (1860), and became the dominant party into the 1930s. Although Debs remained committed to the electoral approach as embodied by a political party, he continued advocating for working-class people to join industrial unions. In 1905, Debs returned to Chicago to help found the Industrial Workers of the World (IWW), perhaps the most powerful, and definitely the most colorful, revolutionary union in U.S. history. Debs and others had many reasons to start a new union. First and foremost was the extreme poverty, suffering, and inequality in America, especially in cities. At that time, a small group of corporations had incredible power, with monopolies and oligopolies dominating every single sector of the economy. However, despite the surge of corporate power, the government did nothing to regulate industry while a tiny group of American capitalists amassed wealth greater than European monarchs could imagine. In addition, the government consistently took employers side in workplace disputes, the courts were deeply conservative, while the military and police essentially provided free security to corporations to defeat workers strikes and crush unions. Worse, workers wanting change received no help from the mainstream labor movement as embodied by the American Federation of Labor (AFL), divided into dozens of craft unions. Debs never seemed more militant than in castigating the AFL at the IWW convention: What we want today, above all things, is united economic and political action, and we can never have that while the working class are parceled out among hundreds, aye thousands, of separate unions that keep them for reasons, many of which they readily suggest themselves. 117 Debss critique of reformist 117 Debs, Debs: His Life, Writings and Speeches, 386. 73 craft unions who embraced bread-and-butter unionism was shared by the two hundred other leftwing radicals who had gathered to found a new socialist labor federation on May Day 1905. Debs was joined in Chicago by other legendary figures such as Mary Harris Mother Jones, the famous union organizer and child labor abolitionist; William D. Big Bill Haywood, the leader of the militant, socialist Western Federation of Miners and chair of what he declared the Continental Congress of the Working Class; Lucy Parsons, the Black anarchist and widow of Albert Parsons who was executed by the state of Illinois after the Haymarket massacre and; a host of other socialists, anarchists, unionists, and revolutionaries from the U.S. but also Canada, New Zealand, and Spain. Wobblies believed that capitalism was the core problem and, thus, the solution was socialism. The IWWs powerful preamble reads, in part, that a new society needed to be fashioned out of the ashes of the old but only after the abolition of the wage system. Wobblies believed that socialism only could be achieved via workers organizing on the job, through revolutionary unions. Debs, however, envisioned the IWWs One Big Union more as the trade union wing of the SPA. In other words, socialists of the SPA variety embraced both economic and political approaches, but socialists of the IWW strip believed people had their greatest power on the job, so should focus their energies there. Big Bill Haywood famously said that workers greatest power involved simply putting their hands in their pockets, i.e. stopping work. However, the Wobblies increasingly rejected electoral politics, believing that economic elites totally controlled the political and judicial systems. Instead, only workplace action could possibly succeed, via the general strike or One Big Strike. What began as a simple disagreement grew over time. Within a few years Debs was not involved in the IWW, and other SPA members like him also drifted away. 74 Then, in 19121913, a major rift occurred between socialists who believe in the SPA and socialists who believed in the IWW. Haywood and other Wobblies left the SPA. Debs ran for president in 1912 when he and the SPA had their greatest electoral success. Keir Hardie, who returned to the United States on several occasions and wrote about U.S. politics for an English audience, was effusive in his praise of Debs and the SPA. The election, no doubt, is fascinating because Debs was part of a four-way race in which all four candidates embraced at least some policies that could be called Progressive and, arguably, socialist. As Hardie wrote: The late Mark Hanna, the Republican boss, predicted that Socialism would be the leading issue in the campaign for 1912. Unless there is a great war in which America will be involved before then, his prediction seems likely to be completely verified. Educated America stands aghast and ashamed at the power of the trusts, their disregard of law, and their corrupting influence upon public life. And so that class is turning to Socialism as the only way of escape. They realise that the nation must own the trusts, or otherwise the trusts will own the nation. The feeling of despair which formerly led good men to wring their hands as those bereft of hope for their country is being replaced by one of confidence in their future. 118 Truly, Debs and the SPAs popularity pulled everyone leftward. Overall, the SPA did relatively well and won hundreds of offices at the local level and hit double digits in a number of western states. President Woodrow Wilson, like Presidents Theodore Roosevelt and Howard Taft before him, enacted a series of Progressive policies thatfor the first time and only partiallyused governmental power, on behalf of the people, to rein in corporate greed and power. In retrospect, though, 1912 proved to be the high-water mark for Debs and the SPA. World War I broke out shortly thereafter, in 1914, and while the United States officially remained neutral, the government actively supported the British and French side against the Keir Hardie, America Re-Visited: Labour Vote To-Day and To-Morrow, The Labour Leader, October 9, 1908. 118 75 Germans. Generally, the U.S. Left was highly critical of the war as well as of European socialists who basically chose nationalism over international working-class solidarity. Such was the line of many Americans on the left, including Debs and others in the SPA. Most famously, in June 1918 in Canton, Ohio, Debs delivered a speech in which he harshly criticized the U.S. war in France. His criticisms were numerous. First and foremost, the working class, who fight all the battleswho freely shed their blood and furnish the corpses, have never yet had a voice in either declaring war or making peace. It is the ruling class that invariably does both. By contrast, The master class has always declared the wars. The subject class has always fought the battles. The master class has had all to gain and nothing to lose, while the subject class has had nothing to gain and all to loseespecially their lives. Crucially, working-class people on both sides of the warsuffered the negative consequences and gained none of the benefits. Additionally, many Americans pointed out that Germany had not attacked the United States and questioned Wilsons argument in favor of war, namely to make the world safe for democracy, as arrogant rhetoric masking imperial ambitions. Of course, Debss critique was hardly unique, but he was the most prominent socialist in America and perhaps the most principled left-wing leader respected beyond the left and the labor movement. 119 Debss speech received very wide attention in the press and from the government. As a result, shortly after his speech, Debs was charged with violating the Espionage and Sedition Acts. His case quickly went to trial, in September 1918, with national coverage. Debs was at his popular apex, during the trial, and delivered some of his most famous remarks. He used the forum to, as always, advocate for his beliefs: 119 Debs, The Canton Speech, 19, 76 I believe, Your Honor, in common with all Socialists, that this nation ought to own and control its own industries. I believe, as all Socialists do, that all things that are jointly needed and used ought to be jointly ownedthat industry, the basis of our social life, instead of being the private property of a few and operated for their enrichment, ought to be the common property of all, democratically administered in the interest of allI am opposing a social order in which it is possible for one man who does absolutely nothing that is useful to amass a fortune of hundreds of millions of dollars, while millions of men and women who work all the days of their lives secure barely enough for a wretched existence. In his remarks at the sentencing hearing, when he could have pleaded for clemency, Debs cried out: While there is a lower class Im in it. While there is a criminal element, I am of it and while there is a soul in prison I am not free. As poignant as those words were, the single word solidarity, associated with Debs if even more so with the IWW, might suffice. Few were surprised when Debs was found guilty and sentenced to ten years in prison. 120 At the age of 63 Debs was incarcerated as federal prisoner 9,653. He spent his first few months in a relatively comfortable state prison in West Virginia before being transferred to a new federal prison in Atlanta. In his new prison Debs quickly found himself in wretched conditions. The food was unpalatable, and he could not eat for two weeks despite working in the clothing warehouse. For fifteen hours each day, he was confined with five other men in a small cell in the southern heat. On a few occasions, it was reported that Debs was near death due to lumbago, heart trouble, blinding headaches, and kidney trouble caused by atrocious food. Debs was, of course, hardly the only human sent to prison for opposing the war. He joined thousands of other Americans and immigrants in what now is called the First Red Scare (with the Second Red Scare commencing after World War II). While in Atlanta, he became depressed as his beloved Socialist Party became bitterly divided over a variety of issues, including how to respond 120 Debs, The Canton Speech, 41-42 and 57. 77 to the newly formed Soviet Union. Debs also worried that the massive government repression which also threatened the existence of the IWW. In prison, Debs became despondent, wondering whether what he had devoted his whole life to would ever bear fruit. Indeed, the world seemed so far from where he hoped it would be. Nevertheless, in 1920 Debs agreed to run for president one more timefrom prison, the first time an American had done so. The SPA slogan was from the prison to the White House! The government, however, made it nearly impossible for Debs to campaign, for instance only allowing him to compose and share one 500-word statement a week. Despite this repression, he received more than 900,000 votes. While it is impossible to know, the large vote total might have been inflated by those in sympathy with Debsbut not Socialism. Many also were deeply upset about his continuing imprisonment when the war had ended two years prior. There was a widespread belief that the Espionage and Sedition Acts were unconstitutional, violating the First Amendment by criminalizing thought as opposed to action. There also was a national campaign to free Debs as well as other political prisoners that emerged in 1919 and picked up steam. In 1920, a new president, Warren Harding, was elected. Ironically, it was Harding, the conservative Republican, who commuted Debss sentence ahead of Christmas in 1921, whereas the Democrat Wilson had been Debss foe. When Debs left the Atlanta prison, thousands of inmates broke out in enormous cheers that could be heard far away and which brought tears to his eyes. After a brief meeting with Harding in the capital, Debs made it home to Terre Haute before years end. 50,000 people welcome him home. He was 66 years old. Debs was weakened by his prison experience and no longer a young man. In his final years of life, he was not as much of a public a figurehaving been weakened by decades of travel and stressthough he did many interviews. He also wrote a series of nationally syndicated stories, in 78 1922, about his prison experiences and his thoughts on incarceration as a system. David Karsner, a long-time collaborator and socialist journalist, brought these together and a few more essays, released the year after Debss death, in 1927, as Walls and Bars. There are countless fascinating aspects of this book, but the basic argument was that the class bias embedded in prisons meant that to identify those who were imprisoned as poor was redundant. He explained why prisons were so unjust for the poor but also that the rich rarely went to prison; instead, the prison as a rule, to which there are few exceptions, is for the poor. For those who believe in equality, the U.S. prison system must be a devastating indictment, for all one need do was look at the prison populationExhibit A for Americas massive inequalities and unfairness. Hence, prisons should not merely be reformed but abolished. And the only way to do that would be revolutionary change to the economic system. Only socialism could succeed in taking the jail out of man as well as taking man out of jail. 121 In his final years, Debs grew weaker. He and his loyal wife still hosted many people at his home in Terre Haute, but on multiple occasions he checked into sanitariums to rest and recover. Debs spent a lot of time, including his final weeks, at one such place in Elmhurst, Illinois, where he passed away at the age of 70. Many thousands of people gathered, soon after, in Terre Haute outside of his house where the funeral ceremony was held in 1926. One way to reflect upon Debss long and impressive life is to consider his increasing radicalization. In his typical fashion, Winston Churchill cynically remarked that, as people age they naturally become more conservative. However, an analysis of Debs contradicts Churchills claim. Ultimately, since capitalism was the root cause of societys great ills including 121 All quotes from Debs, Walls and Bars. 79 unemployment, poverty, war, and prison, the only answer was to move to socialism. Thus, over the course of his life, Debs traveled the opposite path and embraced ever-more left-wing, radical solutions to the worlds problems such as revolutionary unionism and Social Democracy. By the mid-1890s, the solution for Debs became clear, and it remained so for him until his death. It also is fascinating that, in 2021, Debs is better known and more respected than since the 1960s or, maybe, the 1930s. In 2021, the Democratic Socialists of America has increased to nearly 100,000 members in less than a decade; DSA members now serve in the U.S. House of Representatives and in elected office in many cities and states. So, too, the IWW which is larger today than probably since the 1930s. In spring 2021, when this essay was composed, the country was gripped by a widely publicized (soon-failed) campaign to organize a union among Amazon warehouse workers in Bessemer, Alabama. That a majority-Black workforce in one of the poorest states in the country took on the most powerful corporation in America is a sign of the times. In another, many Americans, particularly in the younger Millennial generation and Generation Z, have a more favorable opinion of socialism than capitalism. If Debs was alive today he would be truly excited because, like many Socialists, he was a hopeful person. As he once declared, I am for socialism because I am for humanity. 122 His life continues to provide both lessons and light. 122 Debs, Open letter to the American Railway Union, Chicago Railway Times, January 1, 1897. 80 Bibliography Bernstein, Joseph, ed. Writings and Speeches of Eugene Debs. New York: Heritage Press, 1948. Buhle, Paul, Steve Max, and Dave Nance. Eugene Debs: A Graphic Biography. Art by Noah Van Sciver. New York: Verso, 2019. Cole, Peter. Keir Hardie, Eugene Debs, and the Transatlantic Connection, in Keir Hardie and the 21st Century Socialist Revival, edited by Pauline Bryan, 16580. Edinburgh: Luath Press, 2019. Davenport, Tim. The Young Eugene V. Debs: An interview by Shawn Gude. Jacobin, Aug. 28, 2020. https://jacobinmag.com/2020/08/eugene-v-debs-unions-american-socialism Debs, Eugene Victor. The Canton Speech: With Statements to the Jury and the Court. New York: Oriole Chapbooks, n.d. https://debsfoundation.org/pdf/canton-and-court.pdf -----. Debs: His Life, Writings and Speeches. Chicago: Charles H. Kerr & Company, 1904. -----. The Negro in the Class Struggle. International Socialist Review, 4 (Nov. 1903): 25760. -----. Stand Up and Be Counted. American Guardian, May 10, 1919. -----. Walls and Bars. Chicago: Socialist Party of America, 1927. Ginger, Ray. The Bending Cross: A Biography of Eugene V. Debs. New Brunswick: Rutgers University Press, 1949. Karsner, David. Talks with Debs in Terre Haute. New York: New York Call, 1922. McArdle, Terence. The Socialist Who Ran for President from Prison - and Won Nearly a Million Votes. Washington Post, Sept. 22, 2019. https://www.washingtonpost.com/dc-mdva/2019/09/22/socialist-who-ran-president-prison-won-nearly-million-votes/ Morgan, Wayne H. Eugene V. Debs: Socialist for President. Syracuse: Syracuse University Press, 1962. Salvatore, Nick. Eugene V. Debs: Citizen and Socialist. Urbana: University of Illinois Press, 1982. Stewart, William. J. Keir Hardie, introduction by J. Ramsay Macdonald, MP. London: Independent Labour Party Publication Department, 1921. 81 Migrations: On Breaking Isolation and the Trauma of the Familiar in a Pandemic D. A. Lockhart I am sitting on the forward deck of the Pelee Islander II, in the now not-so-odd warm day in the early part of Falling Leaves Moon, and we are approaching the large federal dock for Pelee Island at Westview. Cormorants slingshot themselves southward toward Middle Bass Island, across the even surface of Lake Erie, crisscrossing the imaginary border between nations. My wife points out the string of cars and work vans heading to the dock. It is rush hour on the island and a small cadre of vehicles move past closed-up shops and restaurants, wave-eaten shoreline, and lifeless houses. This is Pelee in hibernation for humans. Or damned near it. Midpoint of autumn and the summer luster of the island, already faded in the tint of a global pandemic, and it is easy to sense the tiredness of a slow crawl to a blanketed slumber. The slumber, the hibernation, a fact driven by our established human calendar. A calendar that has locked us in with its familiarity. A calendar that most of understand has come to be broken as we limp through a dramatically changed world. Weve come for the first time since the pandemic grabbed hold of creation and strangled the familiar from it. Except here. Except the quiet of this island at the edge of Canada. Weve come in search of, or perhaps despite the familiar. This is not the usual time to visit the island for mainlanders. Or so our everyday has told us. For those that know Pelee, they know that it is high migration season for the birds here. That is nothing of a surprise. Perhaps acting on that very impulse ourselves, we have left our isolation and home-bound life for the first time in months to visit this, our island. Migrations, no matter the distance 82 covered, requires a departure and a coming together. This island of solitude at the center of Waabishkiigo Gchigami marks the first time weve spent more than a few passing moments with strangers. On the ferry, during the one-and-a-half-hour transit, we break our isolation with face masks and arbitrary distances. We are more aware of others by their mere proximity; the photographer, the crew members moving between forbidden spaces, the families huddled together in the forward lounge. Their presence, their movement, makes the brief window of our time together more real and tangible than any of the previous months or moments or afternoons or evenings that have passed over the last year. In this shared time, all of this is tentative. None of us move with any certainty. The familiarity, the comfort of repeated transits, is gone. Each of us wants to move as if by memory, yet hold back these motions out of the reality that has settled atop us. Fear of connection that may ultimately kill us. Our world has changed, we all know it, but all desperately push on in the way that news media, government officials, and business owners have told us to. And the ferry cuts the waters beneath us like it always has. The flag before the township hall still sways in the persistent westerly winds. There is one person standing on the deck of the Westview Tavern, likely smoking, taking in the sudden business before them. Before us is the departure part of this migration. But what of the coming together? Arent there too few of us to count a coming together? We shall remain as isolated as before. Is this what generations of bird migrations have come to experience, too? We recognize how little has changed in our absence. We, also recognize how the fabric that holds those things in place has frayed and is a continual process of unwinding. We are called to our cars below decks as the ferry comes into dock, stopping broadside to the island, then reversing into its spot on the federal pier. We move through the three stories and sparsely peopled ship. In our well-worn Subaru we wait, separated by steel and plastic and glass from the belly of the boat and our fellow travelers. Our landfall is marked by the ever-so-slight shifting of our weight, 83 the jarring chirp and grind as the Pelee Islander IIs skin rubs alongside solid footing. Our safe passage ends in the pregnant pause between stillness and the opening of the ships loading ramp. Car taillights and engines spark to life. The cold metal shadow of the car deck is flooded by the sunlight afforded by the lowering of the ramp. One by one, we and our fellow travelers are guided from the belly of the boat. We burst into the brilliant fall afternoon light. The whole process is a momentary blur of motion and land. Even in passing, none of this feels as it should. Not familiar, not strange. It is all mechanical, but there is something askew. Isolation in hermetically sealed cars, all of us. We dont celebrate this arrival. Instead, we dissipate into the tree cover and farm fields like the other flocks passing through the island. We can talk about isolation again. Not because of the raging pandemic. But because islands can isolate and merge. And how medicine for what ails us is often found through the gifts provided by being alone. We speak of it in negative terms, of how isolation is the second scourge of this apocalypse. We are awash in half-truths wielded by capitalists that want nothing of our world to change from its current course. This wave breaks in unending opinion pieces about shadow suicides and the type of long-term psychological damage that settlers forced on First Nations through residential schools. Its all hyperbole. The sort of thing politicians and propagandists build careers upon. But those half-truths have no footing in a place that has failed to garner the capitalists eyes. A reservation against the world around us, we are afterthought here to those on the mainland. An afterthought that means no islandwide viable drinking water system, spotty internet, dirt roads, and intermittent power. And in that afterthought is an act of salvation, a lapse that lets truths of the world pour in around weekday grocery 84 fliers and media predictions of housing values and new farm-to-table eateries. Pelee is the world striped down to its bare essentials: dry land, sun, wind, bird song, the cries of distant foxes. We have merged then surged forward, alone from the murmur of the other cars, along the roadway we see the cars hustle down toward the ferry. This island, a shallow-lake mountain top, an anchor of terrestrial life in a fresh-water sea, stretches out before us in canyons of some of the oldest trees in Essex County. Weve come home here, surrounded by relations that breathed the same air as our ancestors, felt the steadily warming sun and air against their bodies. The living memory of the western Lake Erie basin in the form of Carolinean trees, shrubs, grasses, and wildflowers embraces us as we drive with windows open to the island air. We make our way to a rental cottage for the weekend, our land here in no shape for our tipi. Pelee surges in waves of starlings, killdeers, guided by herons, sung into motion by wrens and kinglets. Trees, mostly still green and late-summer lush, hold fast against the fall that the rest of Canada has already mostly descended into. Pelee breathes out, and it surrounds us in the warm embrace of a family reception. During the first months of this pandemic world we felt it shrinking to something no further in perimeter than our small urban encampment in Pillete Village at Waawiiyaatanong. The world had slowed to a quiet crawl. Our lives mirrored the isolation that we heard about through radio and nightly news broadcasts. Perhaps there were truths to their stories. The absences that ran through our new reality made it hollow, without air traffic, trains, the arrival of relations, the quiet of life without the familiar, the expected. Isolation perhaps exists only in the familiar. Or in light of its absence. It is what we believe and understand that we are missing. Our lives conceal from us the manner that we are rarely physically alone. Once the news and radio are turned off, our smartphones hidden from sight and retrieval, this realization nestles itself down. How creation creeps back into the spaces stolen from us by tight-packed urban housing, suburban tracts of neutered earth, crash of a wide-freeway, it all 85 becomes apparent. Creation promised to us by our ancestors returns in slow-tentative starts; wild turkeys in back allies, foxes sleeping in tulip beds, eagles dancing between skyscrapers. We are still close enough to others, there are at least hundreds of other people within a few blocks of your fortress of solitude. One is alone only in your mind. Even here on this island, with a fraction of the citys population, that notion of alone is at best wrong. We pull up to the small yellow cottage surrounded by farm fields and an active (or as active as Pelee ever gets) quarry as neighbours. The gravel road that runs alongside the house is an afterthought. There are no people around us for at least a kilometer and yet we feel more embraced and welcome than we had in the previous half-year. Here we rest in the outskirts on an island on the outskirts of a nation. It is alive and full here despite location. Isolation is a word best suited to the world it cant possibly describe. It has no place here. The elm and sycamore branches chatting in the persistent wind. The woodpecker catching bugs from the sunroom walls, the persistent motion of startling and cowbirds. One is welcomed into a family, into a home that youve forgotten. The scent from the lake drifts in through the hedgerows, brough on the cooling air, thick with the dust from pickups floating in from distant traversed roads. There is no absence here. You know because you instantly forget about that half-life youve been sleeping through, big-box store parking lots, tight-packed dining rooms, the anger of customers required to wait more than the thirty seconds they envision as proper. Here, the dance of a chickadee from the shed to the sugar maple to cars roof-rack is all that matters. It is that very thing you know youve been missing. Since well before the pandemic shattered the world. In isolation, this type imposed by the act of crossing a great lake and found on islands in their midst, we find a connection. We are part and parcel of the world around us. You feel it, you breathe it in through the cutting western wind. You feel it in the heavy thuds of waves crashing against the nearby northern shore. This is the world, the living breathing part, that youve missed while locked up 86 inside your home since late winter. Its one youve missed being locked up inside for the better part of three decades. Where I stand is relatively empty of people, yet full of life. The very antecedent of what we are told we must feel when we hear the word isolation or alone. In fact, our singular physical bodies are never alone. We are Blakes universe in a grain of sand. Our existence touches an endless array of living beings. We touch creation, feel welcome in it, because we are creation. We feel our relations through the rustle of leaves in the wind, the call of flickers as they dance through ash trees, the scraping of squirrel claws in bark as they run up the nearby sycamore. This is world that actually exists beyond marketing campaigns and nightly news briefs. It is the one that embraces us, invigorates our senses, draws us to the gift of life, of the lives weve been afforded in its presence. This reminds that there is past, a present, and a future and we are all part of it. It has taken a migration to arrive here. The natural process by which living beings connect to the rich tapestry of a gift the land itself has always afforded us. Walls and borders have no place in the world we were gifted. One can witness the blue jays, the orioles, the cormorants move as our ancestors; at will and as required. Isolation, in its honest form, is the prison that has been crafted by distant men wishing nothing more than to squeeze each bit of power and material from the world for their own gain. One of the first moves of the torturer is isolate the victim. One of the first rules of survival is to break that isolation. Migration is that step. In motion we break those loose connections. At rest we rediscover the world unburdened by that thin-shallow understanding of life itself. To migrate is to reconnect. To rest upon the land is to contemplate and understand that connection. Standing upon the deck at this cottage on the north side of Pelee Island on an early autumn day, I am well nestled in that second part. And this second part is the first truthful view of the pandemic world. This is the realization that any sense of isolation is misinformation, grown out of a blind comfort that has been shaken by a ripple in the fabric of how we have come to engage over time. We were tricked into a sense of comfort by Black Friday sales, smart homes, the warmth of flat87 screen televisions saturated with Netflix shows. The pandemic shattered that comfort, illustrated the hard truths of the world. We have been forced to change and then sit in the ruins of the thing weve been forced to leave behind: crowded craft beer festivals, sold-out sports stadiums, people watching from downtown caf patios, sardine can airline flights. From this angle all we can see is the shattered bits of the familiar, the parts that brought us joy in lieu of trading our finite time for money. We love and miss them because they have become familiar, the things that we have always simply done to be happy and have been unwilling to see the faults of our ways. The very sort of faults that have led to a destabilized ecosystem, massive income disparities, and a raging global pandemic. We were failing Creation and each other. And must change the familiar. We must defamiliarize our place in this moment. A difficult task either to accomplish or to set out to accomplish with the bubbling trauma and disease that surrounds us. Yet we must because it is critical to survival. And survival is difficult in the best of times. That act or attempt has landed me here. A migration of sorts. This is not to say I am unfamiliar with Pelee. Weve been coming to the island for years. But it still lacks the familiarity of the everyday Ive come to experience in my home back at Waawiiyaatanong. The old, ordered sense of movement, along numbered highways, streets named for rich colonizers, and the big-box stores that take root alongside them. The way we have come to expect our time and lives to unfold. Measured by the market economy calendar anchored by Black Friday and Back-to-School Sales. An order that has gifted us with a simultaneously burning and sinking planet weve come to witness around us. And while it was always there, it was that we were far too exhausted in our old wrong ways, we could not see outside of its detritus. Our world and our lives are stratified, dramatically, and the view from afar, from the common ground beyond, was the only true manner to examine the damage. Here on Pelee there is one co-op, a bakery, a LCBO, two restaurants, and winery. Nature controls who those people are and when they arrive by the sheer force of the lake and the changes between seasons. Our calendars are set to migrations, both avian and human. As 88 such, our time here is measured in arrivals and departures. Those arrivals and departures are measured by seasons. Our sense of being, our sense of measurement, our connection point becomes tied to creation itself. We are no longer alone with the mechanical time-out-of-mind measurement of lives. It is the next day as we make our way through Nature Conservancy land on the east side of the island that these thoughts come back to me. As the afternoon slides into evening, we visit the old farm field the Nature Conservancy has rehabbed into pathways of wild echinacea, naturalized tall grasses, and ponds. Before us the ultimate act of reclaiming creation from the darkness of a mechanical disconnected world. It is a breach from the common, the expected even on this island. Healing looks like this. It is a reconnection of species and ecosystems, an answer to isolation. We wander through this crack from the work-a-day soybean farms, the vineyards, the towns of cottages. Here is the island as it was engendered by Creation to be. The island before the McCormicks and generations of settlers to follow them. In the sweetened air above the restored habitat, it is easy to sense the warm buzz of space filled with life. This is the ancient honest feel of the land, from when Anishinaabe and Haudenosaunee set up camp here generations before settlers plied the lakes with their migration of ferries. This feeling, too, was familiar, common. It gets at the lie of the isolation of the pandemic. Illustrates the extent to which our own choices have led to majority of loneliness in this pandemic. This restored portion of Creation is the break in our common. As our common was the result of shrinking three islands into one through the draining of marshland, reshaping the ancient familiar, making an island in this archipelago resemble the farm fields of the distant mainland. This is the island of our dreams, of our past, the must be in our future. We walk through the field, following the trampled down portions of wild echinacea to the distant man-made hummocks, encrusted with prairie grasses and desiccate flowers. The quiet here carried by wind from the far side of the island. Only the intermittent clatter from distant vineyards chasing off hungry birds breaks it. This is the land as dreamed. This is the survival that we all wish 89 possible. We are alone with everything. Isolation, quiet in its means solitude, compiled in several world flowers, cloudless blue fall skies. He we are reborn into our ancestor family with each step though the field. Unfamiliar only to our recent generations, learned through urban indoctrinations of late capitalism, the life before us. Each step atop this reclaimed flower carpeted path is an homage, a healing, and return to the ancestral meaning of what it is to be alive in the vibrancy of creation. And it is at a break in the paths that we spook from the thicket at that paths edge a flock of turkeys. They burst into daylight, the same mottled colours and texture of the Earth itself. Sprung free from a dormant earth, it is both a sharp alarm to their presence, followed by the excitement of proximity to another living, breathing, creature, and one that a great many us would not be able to call familiar. Whatever notions of isolation we still harbour are obliterated in that moment. Even in the invisible here there is life, there are our relations. In migration, weve returned home to this reclaimed field on the east side of Pelee Island, and we can witness the truth that lies ahead, that shall always lie ahead. Our world in flux, in illness, in the quiet between greater things, is temporary. Our isolation an imagined emotion. Our isolation another self-imposed sickness. And what lies ahead, through all the migrations that await us we shall behold the promises that have always been here. We are never alone, so long as our bodies touch the warmth of Creation beneath our feet. 90 The Power of Theatre in the Time of an American Nero Marcia Eppich-Harris After the inauguration of Joe Biden, I have been hesitant to think about, or write about, Americas forty-fifth president. The years 20162020 mark an era I have no interest in reliving. But there is a certain amount of responsibility one must embrace as a citizen of a democracy, and within that responsibility is the obligation of remembrance. We are tasked with remembrance for a number of reasons, among them setting precedents or opposing them. I would argue that it would be best to temper the instinct to forget all about Donald Trump, post-inauguration, no matter how much we would like to, but only to ensure that Trumpian politicians are irradicated from American government through our electoral processes. If we fail to take seriously the insurrection of January 6, 2021, when Trump supporters raided the Capitol, some seeming intent on hanging Vice President Mike Pence, 123 and others smashing windows, beating police, and causing the deaths of five people and the injury and COVID-19 infections of dozens more, 124 then our democracy is utterly doomed. There are plenty of ways our remembrance duties can be fulfilled, but I would argue that the freedom to examine politics and history exists in theatre in ways that cannot be replicated in nonfiction, journalism, social media, or everyday life. The Trump presidency inspired an incredible Martin Pengelly Hang Mike Pence: Twitter Stops Phrase Trending after Capitol Riot, Guardian, Jan. 10, 2021, https://www.theguardian.com/us-news/2021/jan/10/hang-mike-pencetwitter-stops-phrase-trending-capitol-breach. 124 Jack Healy, These Are the Five People Who Died in the Capitol Riot New York Times, Jan. 11, 2021, last modified Feb. 22, 2021, https://www.nytimes.com/2021/01/11/us/who-died-in-capitolbuilding-attack.html. 123 91 amount of critical writing: speeches, biographies, tell-all books, and sociopolitical criticism. 125 However, as both a literary scholar whose specialization is Shakespeare and a creative writer, I am more prone to think about Trump in Shakespearean, theatrical, and metaphorical dimensions. Significantly in todays partisan landscape, we can sidestep partisan leanings in theatrical productions and be encouraged to consider a specific story or event that might resonate with our own moment without alienating members of either party. A famous case in point came in 2016, within weeks following the election. Then Vice-President-elect Mike Pence saw Hamiltona pointedly progressive showon Broadway. The crowd booed Pence, 126 and yet, even as those in his party were allegorically criticized by the rhetorical thrust of the play, Pence reportedly enjoyed the show. The fact that Pence listened to the Hamilton cast when they addressed him from the stage after the curtain call is so stunning and anomalous that it hardly seems possible that a similar, respectful action would be taken in response to say, John Boltons book The Room Where It Happened, a title that recalls a pivotal song in Hamilton. See, for instance, David Frum, Trumpocracy: The Corruption of the American Republic (New York: Harper Collins, 2018); David Cay Johnston, Its Even Worse than You Think: What the Trump Administration is Doing to America (New York: Simon and Schuster, 2018); Omarosa Manigault Newman, Unhinged: An Insiders Account of the Trump White House (New York: Simon and Schuster, 2018); Bob Woodward, Fear: Trump in the White House (New York: Simon and Schuster, 2018), Cliff Sims, Team of Vipers: My 500 Extraordinary Days in the Trump White House (New York: St. Martins Press, 2019); Anonymous [A Senior Trump Administration Official], A Warning [New York: Hachette Book Group, 2019); Philip Rucker and Carol Leonnig, A Very Stable Genius: Donald J. Trumps Testing of America (New York: Penguin Press, 2020); John Bolton, The Room Where It Happened (New York: Simon and Schuster, 2020). 126 CNN reported that Pence said he did notice the booing, but it didnt spoil the show. My daughter and I and her cousins really enjoyed the show. Hamilton is just an incredible production, incredibly talented people. It was a real joy to be there, Pence said. When we arrived we heard a few boos, and we heard some cheers, he said, I nudged my kids and reminded them that is what freedom sounds like. Eric Bradner, Pence: I Wasnt Offended by Message of Hamilton Cast, Nov. 20, 2016, CNN, https://www.cnn.com/2016/11/20/politics/mike-pence-hamilton-messagetrump/index.html. 125 92 I am certainly not the only person to think of Trumps presidency as a living literary metaphor and cautionary tale. Stephen Greenblatts book Tyrant: Shakespeare on Politics (2018) makes oblique references to Trump as it works through Shakespeares major and minor league neer-do-wells, although never naming the forty-fifth president explicitly. James Shapiros Shakespeare in a Divided America (2020) discusses the controversial Public Theatre production of Julius Caesar (2017) in which the eponymous character is dressed like Trump, including a wig, and is assassinated by women and people of color. A more classical version of Julius Caesar was produced in the summer of 2017 by the Royal Shakespeare Company (RSC) in Stratford-upon-Avon. In fact, the RSCs season in 2017 consisted of entirely Roman subjectsa feat not attempted there since 1971. While the RSC productions did not attempt to connect with Trump in their staging, a full-page picture of Trump and Barack Obama in the program for Julius Caesar made clear that the season linked the political present to the theatrical past, as we are often prone to do. Famous twentieth-century examples include Orson Welless Caesar, which commented on fascist Italy and Nazi Germany, and Laurence Olivers 1944 film version of Henry V, aimed at bolstering British morale in the war. 127 In 2017, I was preparing to teach an honors class about Shakespeares Roman and history plays, so I was deeply engaged with Shakespeares historic subjects, and of course, the major influences on his writing. It occurred to me after seeing their productions of Julius Caesar and Antony and Cleopatra that what was missing from the RSC Roman season was a tribute to the first-century Stoic philosopher and dramatist Seneca, whose work influenced Shakespeares tragedies and histories. Seneca was an important political figure in ancient Rome, too. He had been the tutor and chief advisor to the emperor Stephen Greenblatt, Tyrant: Shakespeare on Politics (New York: W.W. Norton, 2018); James Shapiro, Shakespeare in a Divided America: What His Plays Tell Us about Our Past and Future (New York: Penguin Books, 2021). Henry V, dir. Laurence Olivier (Two Cities Films, 1944). 127 93 Nero in the hopes that his Stoic philosophy would rub off on him. Ultimately, Senecas attempts to make a Stoic out of Nero failed. I decided after that RSC season that I wanted to write about Seneca and Nero. I had taught Senecas plays in my Humanities classes, and I knew some of the history behind his relationship with Nero. I started a leisurely bit of research on the pair, reading James Romms book, Dying Every Day: Seneca at the Court of Nero (2014), and reading all of Senecas tragedies. 128 When the anonymous op-ed I Am Part of the Resistance Inside the Trump Administration was published in the New York Times (September 2018)129 I could not stop thinking of how that senior official in the Trump administration seemed very much like Senecaat least in the way they described themselves. 130 The germ of an idea was planted in my mind. But it wasnt until Tuesday, September 24, 2019, when Speaker of the House Nancy Pelosi announced that an impeachment inquiry would commence against Trump, that I knew what I wanted to write. I opened a new file on my computer and started an allegorical play about modern America, starring Seneca and Nero. Thus, the writing of my play Seneca and the Soul of Nero began. I dont always have such a clear path to inspiration when I write, but in my mind, Seneca and Nero were the perfect historical and allegorical characters to represent the presidency and ambivalent administration of Donald Trump. Trumps narcissism, and his Romanesque hedonism, strongly 128 James Romm, Dying Every Day: Seneca at the Court of Nero (New York: Knopf, 2014). I Am Part of the Resistance Inside the Trump Administration, New York Times, Sept. 5, 2018, https://www.nytimes.com/2018/09/05/opinion/trump-white-house-anonymous-resistance.html 129 CNN later reported that Miles Taylor, chief of staff to Department of Homeland Security Secretary Kirstjen Nielsen, wrote the anonymous op-ed, as well as the book A Warning that included many more details about the behind-the-scenes stories within the administration. See Jake Tapper and Jeremy Herb, Author of 2018 Anonymous Op-Ed Critical of Trump Revealed, Oct. 28, 2020, https://www.cnn.com/2020/10/28/politics/anonymous-new-york-times-opedwriter/index.html. 130 94 matched Neros. The anonymous op-ed writer, later revealed to be Miles Taylor, described almost exactly the sort of position Seneca occupied in Neros reign. Taylor stated, We want the administration to succeed and think that many of its policies have already made America safer and more prosperous. But we believe our first duty is to this country, and the president continues to act in a manner that is detrimental to the health of the republic. 131 Taylor went on to describe Trumps leadership style as impetuous, adversarial, petty and ineffective, 132 a description that could certainly be applied to Nero. Seneca, like Taylor and his colleagues, constantly tried to temper his leaders worst instincts without success. Despite Taylors reassurances that there were adults in the room who were virtuously fighting for America, Trump continued his erratic governance, with more cabinet member departures than any of the former five presidents, according to the Brookings Institute, 133 as well as attempts to defund the Postal Servicepossibly to interfere with the 2020 election during the COVID-19 pandemic. With government officials from Rex Tillerson and John Kelly to more recently Dr. Anthony Fauci desperate to quell Trumps legally and ethically questionable moves over the past four years, I have been continually reminded of Senecas failed attempts to stop Neros worst instincts. Taylors realization that his and his colleagues approach to Trump was doomed to fail is a stunning parallel. In an interview with CNN, Taylor said, The country cannot rely on well-intentioned, unelected bureaucrats around the President to steer him toward whats right. . . He has purged most of them anyway. 134 I Am Part of the Resistance Inside the Trump Administration, New York Times, Sept. 5, 2018, https://www.nytimes.com/2018/09/05/opinion/trump-white-house-anonymous-resistance.html 132 Ibid. 133 Kathryn Dunn Tenpas, Tracking Turnover in the Trump Administration, Aug. 14, 2020, Brookings Institute, https://www.brookings.edu/research/tracking-turnover-in-the-trumpadministration/ 134 Tapper and Herb, Author of 2018 Anonymous Op-Ed Critical of Trump Revealed. 131 95 That said, I will admit that I am far more sympathetic to Seneca than I am to any Trump official, partly because of the distance of time and partly because Seneca had fewer choices in his political system than we have in America. Nero was only a teenager when he ascended to the imperial throne, aided by his mother, Agrippina, who assassinated her husband, Claudius, to put Nero in power. There was no democratic election; Nero ascended through murder, and he was not the first nor last to do so. Agrippina had recalled Seneca from exile 135 to be Neros tutor when he was a young teen and made him Neros chief advisor. Agrippinas recall and appointment meant Seneca owed the family, and with a family that killed its own, one needed to be carefully compliant. So, while Senecas insider status in Neros reign had similarities to Trumps insiders and cabinet members, the stakes were far higher for Senecaa matter of life and death. For that, as Ive said, I felt sympathy was warranted. Meanwhile, I felt that Taylors presentation of the alternative, virtuous Trump lackey was a pseudo-attempt at presenting his Stoic martyrdom to the world. Our pop psychology definition of stoicisma repression of emotionsis a very shallow understanding of the philosophy. While it is true that in the Stoic tradition, according to the Stanford Dictionary of Philosophy, the ideal agent has no emotions, it is also true that The ideal agent has good feelings of wishing (which replaces desire), caution (which replaces fear), and joy (which replaces pleasure). 136 What Seneca shows in his writing, and I try to show in my representation of Seneca as a character, is that his utmost concerns are living ethically and using reason to improve himself so that he may become virtuous. My own introduction to Stoicism was through Shakespeares complication of the philosophy in his Roman plays, particularly According to James Romm, Seneca was accused of adultery with Caligulas sister, Livilla, as a matter of political expediency. Claudiuss wife, Messalina, wanted both Livilla and Agrippina to be removed from Rome so that she could consolidate her own power over the emperor. Seneca happened to be a convenient man to accuse of adultery with Livilla, as they had a close relationship. He was sentenced to death for his supposed crime. However, Claudius commuted the sentence to exile in Corsica. See Romm, Dying Every Day, 2528. 136 Katja Vogt, Seneca. 3.3 The Therapy of Emotions, Stanford Encyclopedia of Philosophy (Palo Alto: Stanford University Press, 2020), https://plato.stanford.edu/entries/seneca/#SenSto 135 96 in Julius Caesar and Antony and Cleopatra. 137 But as I learned more about Stoicism from reading Senecas philosophical works and dramas, I realized that my own philosophical leanings happen to coincide strongly with Senecas, despite Shakespeares caveats. It was through reading Seneca that I was inspired to think much more deeply about Stoicism. However, when faced with Shakespeares warnings that Stoic ethics cannot shield a person from an unethical tyrant, one wonders if it pays to be ethical. And yet, Stoics would say seeking virtue is its own reward. In other words, it matters that you seek to be virtuous, even if you do not always succeed. Compare this noble concept of virtue seeking with the flagrantly unethical Trump administration and the chaos that has resulted from Trumps tactics, and one can see the appeal of a philosophy that, as Ryan Holiday writes, advises its followers to Take obstacles in your life and turn them into your advantage, control what you can and accept what you cant. 138 For the novice Stoic, Senecas writings, both philosophical and dramatic, are an excellent gateway. He is often didactic in his approach and asks the reader to follow his example in using reflection and reason in the quest for self-improvement. In his treatise On Anger, Seneca gives a prescriptive example of how one should deal with personal shortcomings: I pass the whole day in review before myself, and repeat all that I have said and done: I conceal nothing from myself, and omit nothing: for why should I be afraid of any of my shortcomings, when it is in my power to say, I pardon you this time: see that you never do that anymore? 139 Shakespeare suggests in both Brutuss and Antonys failures and suicides in the two aforementioned plays that Stoicism fails to neutralize Machiavellian realpolitik, however attractive the tenants of Stoicism. 138 Ryan Holiday, Stoicism: Practical Philosophy You Can Actually Use, blog post, June 17, 2014, Ryan Holiday: Meditations on Strategy and Life, https://ryanholiday.net/stoicism-a-practical-philosophyyou-can-actually-use/ 139 Seneca, The Fifth Book of the Dialogues of L. Annaeus Seneca, Addressed to Novatus. Of Anger, Book III, sec. XXXII, https://en.wikisource.org/wiki/Of_Anger/Book_III#XXXVI. 137 97 The idea that self-improvement is something that must be addressed routinely shows that emotional regulation and self-care were practices that Seneca struggled with himself, but ones failings are not something to dwell on, Seneca saysyou can do better next time. Senecas one-day-at-a-time mentality feels progressive and modern to me and suggests that failure is not the end of any given situation. And yet if were to believe Tacitus, Suetonius, and others, Seneca failed to fashion Nero into a virtuous man. This failure ultimately led to Senecas death. In my play, Seneca nevertheless persists not only because he believes it is his Stoic duty to mentor Nero, but also because he cares for him, thinking of him as a son. Seneca and the Soul of Nero opens on the day that Claudius dies and Nero, in effect, becomes emperor. Seneca and Nero have been interrupted in their studies of the Curse of the House of Atreus, a revenge myth that Seneca writes about in two of his tragediesThyestes and Agamemnon. Senecas wife, Pompeia Paulina (nicknamed Poppy), opens the play, saying, I thought you were teaching today, husband. Or has Nero claimed omnipotence already? 140 Poppy is a far more important character in my play than history suggests. Her virtue and wit match her husbands, and she is a true partner to her philosopher husband. She knows that Nero is impetuous, but charmingas we see when friendly banter between the titular characters that tilts toward danger: Nero: Philosophy, psh! You do not like to laugh, Master Seneca. Seneca: I laugh at you every day! Nero: (Joking) To your peril, my friend. 141 While Seneca and Nero tease each other amiably, the purpose of the scene is to set up the tension in their relationship. From the beginning of the play, you see that while Seneca and Nero are close, as teachers and students sometimes are, the power balance between them is always askew, in this case Marcia Eppich-Harris, Seneca and the Soul of Nero, unpublished manuscript, act 1, scene 1, p. 1 (in Marcia Eppich Harriss possession). 141 Ibid., 5. 140 98 with the student rather than the teacher having the political upper hand. I see this sort of tension play out in the Trump administrationfrom when Trump, a political novice, demanded loyalty from James Comey to his infamous telephone call with Volodymyr Zelensky, the president of Ukraine. Neros murders of his support system, including his mother, Agrippina, his first wife, Octavia, his second wife, Poppaea Sabina, 142 and the ordered suicide of Seneca mirror Trumps dismissal of members of his administration who were once avid supporters, such as Jeff Sessions, Reince Priebus, and John Bolton, among many othersnot to mention Trumps stoking of violence in the Capitol insurrection by telling domestic terrorist supporters that he loved them in a video statement on January 6, 2021. In writing historical fiction, a writer frequently takes liberties with causation and timing of events to tell a good story. Shakespeare, for instance, telescoped time constantly in his history plays, collapsing several years into one play and only portraying events that illuminate specific themes. In most cases, Shakespeare used the politically correct version of a character (politically correct for his time) and illustrated them in a way that would please the reigning monarch and the censors, whether that portrayal was true to historic fact or not. Both Prince Hal and Richard III are good examples of Shakespeare towing a party line, regardless of the historical accuracy (or inaccuracy) of his sources. In my play, I collapsed several years into two hours, and in doing so, I had to make choices about what to portray, using episodes that showed causal relationships between events to make a point. I selected scenarios that I felt would show a strong connection between current events and Neros reign, as well as juxtapose Stoic virtue and narcissistic villainy. For instance, Tacitus reports that Nero killed his then-pregnant second wife, Poppaea Sabina, by kicking her to death during a tantrum. 143 This event Poppaea Sabina is the historical name for Neros second wife. I use the name Sabina to distinguish her from Senecas wife, Pompeia Paulina. In the theater, the names might easily be confused. 143 Tacitus, Annuals of Imperial Rome, trans. Alfred John Church and William Jackson Brodbribb (Pantianos Classics, 2017), 245. 142 99 happened in 65 CE, after the great fire of Rome and Senecas forced suicide. However, I changed the order of these events for the sake of social commentary. In my play, Nero kills Poppaea Sabina, then in revenge for his own mistake, he punishes Rome by setting it on fire, destroying the city while he mourns in Antium, keeping Seneca, who had asked to retire and was denied, at his side. In the next scene, a conspiracy to overthrow Nero is unveiled, and Nero condemns Seneca to suicide. In Tacituss account, the conspiracy was to put Gaius Calpurnius Piso, an aristocrat, on the imperial throne, but Romm notes that it might have been the desire of the Praetorians, led by Subrius Flavus, to put Seneca himself on the throne. 144 For a streamlined dramatic effect, I edit Piso out of the picture to focus on the conflict between Neros and Senecas points of view. The chain of events in the play allegorically represents Trumps first impeachment. His own misbehavior caused Trump an incredible number of personal and political headaches, including impeachment, but more significantly, his actions punished America for electing him. After the Capitol insurrection, Trump was impeached again, and yet, the Senates acquittals in each impeachment trial suggest to me that the America I had believed inwhere politics could be set aside to address clear wrongdoingshad been unequivocally lost, or perhaps never existed in the first place. What virtue, if any, is extant in America? Perhaps a Stoic such as Seneca can inspire us to seek it out in ourselves. I am not the only person to equate Trump with Nero or to bemoan a lost sense of virtue. Although I started writing my play long before it was published, a book titled American Nero: The History of the Destruction of the Rule of Law, and Why Trump Is the Worst Offender was published just before Trumps impeachment trial. 145 As the Washington Post reported, the book centers around the icy, granular detail, of what has happened to constitutional democracy in three short years, and all that we have absorbed, Romm, Dying Every Day, 181. Richard Painter and Peter Golenbock, American Nero: The History of the Destruction of the Rule of Law, and Why Trump Is the Worst Offender (Dallas: BenBella Books, Inc., 2020). 144 145 100 integrated and somehow moved beyond. In some sense, then, it stands less as a unified argument than as a scrapbook of things that no longer horrify us. 146 In retrospect, several months later, no one could have predicted Trumps impending failuresnot containing the COVID-19 pandemic and inciting insurrection. Ironically, a month after the first impeachment trial concluded, on March 9, 2020, #NeroTrump was trending on Twitter after Trump retweeted a meme of himself playing a violin with a fire burning in the background, captioned, My next piece is called. . . Nothing can stop whats coming. 147 Trump wrote in his tweet, I dont know what this means, but it sounds good to me. Critics jumped on Trump, as former Federal Bureau of Investigation Assistant Director and NBC News contributor Frank Figliuzzi did: It means that playing golf while Americans die during an uncontained epidemic makes you look like the Emperor Nero fiddling while Rome burned. The fact that neither you nor your social media director understand this meme and retweeted it makes you even more oblivious than Nero. 148 Continuing the analogy, Bernie Sanders, in his speech at the Democratic National Convention, said regarding Trumps handling of the pandemic, Nero fiddled while Rome burned; Trump golfs. His actions fanned this pandemic, resulting in over 170,000 deaths and a nation still unprepared to protect its people. 149 Dahlia Lithwick, Defending the Rule of Law in the Trump Era, Washington Post, March 20, 2020, https://www.washingtonpost.com/outlook/defending-the-rule-of-law-in-the-trumpera/2020/03/19/7dfac5d0-618a-11ea-845d-e35b0234b136_story.html 147 According to The Hill, the tweet was originally posted by White House social media director Dan Scavino on March 8, 2020. 148 Frank Figliuzzi (@FrankFigliuzzi1), playing golf while Americans die during an uncontained epidemic makes you look like the Emperor Nero fiddling while Rome burned, March 8, 2020, https://twitter.com/FrankFigliuzzi1/status/1236793534964883456 149 Bernie Sanders, transcript of speech to Democratic National Convention, Aug. 18, 2020, National Public Radio, https://www.npr.org/2020/08/18/903398536/watch-bernie-sandersspeech-to-the-democratic-nationalconvention?utm_medium=social&utm_campaign=politics&utm_term=nprnews&utm_sou rce=facebook.com&fbclid=IwAR2Zj084P_-bX_XP4O448VwvNUK-mc943sI8zK3Un5EJJLFAW3Ta6Bcr1g. As of June 19, 2021, there have been almost 600,000 deaths from COVID-19 in the United States according to the CDC Covid Data Tracker. See https://covid.cdc.gov/coviddata-tracker/#demographics. 146 101 In all, it took about seven months to complete Seneca and the Soul of Nero, although I had been mulling over the idea for some time. For me, writing about Seneca was cathartic, especially knowing that his position in Neros court must have felt like climbing a mudslide. But writing this play also reminded me that the arts, especially theatre, have a crucial place at the political and historical table. In Seneca and the Soul of Nero, every major character dies with no Horatio left to tell their stories or mourn them. To me, it was important that every character died, not because Im morbid but because I wanted to show the totality of the destruction wrought by Neros pathology. If we had been forced to endure another four years of Trump in the White House, I believe the American republic would also have suffered a similar calamity. This is why writers must document the cycles of political history in the arts to remind ourselves of what were capable of as human beings, both for good and ill. As a demonstration of this belief, I wrote two different scenes in my play in which Seneca is writing tragedies to teach Nero. In writing both scenes, I felt an intimate connection to Seneca that collapsed the 2000 years between our historical moments. At heart, both Seneca and I are teachers, and we both believe in trying to do the right thing, working toward self-improvement despite inevitable failures, and honoring reason and virtue. I can relate to Senecas desire not to give up on Nero, as a teacher so often does not want to give up on her wayward students. Nor do I want to give up on America. While its true that Trump was not elected to a second term, with voters admonishing his administrationunlike the craven Republican Senators who voted twice not to convict Trump of high crimes and misdemeanorsin the greater scope of history, we often do not learn the lessons that we should. Playwrights, therefore, must not cease to engage creatively with history, politics, and philosophy. It is our duty to cut through the grind of endless partisan chatter. The art that we create in this era can last longer than the tell-all books of fired cabinet members. And as with Shakespeares and Senecas works, our contemporary plays will have something to tell future generations about our past and their present simultaneously. 102 That said, if Seneca and the Soul of Nero is only about the Trump administration, then its not a very good play. The larger questions in the play about leadership, Stoicism, ethics, duty, and virtue are themes that have been around for a long time. Shakespeare thought about them; Seneca thought about them. If past is prologue, theres a good chance that we will always have to think about these themes. What we will conclude is anyones guess, but I think its the playwrights duty to encourage audiences to refine our sense of what our obligations are as citizens, and the first, and perhaps most important, obligation is to remember. 103 A Long Time from Burdick Street Luanne Castle Five years ago, I stood near the push-to-walk button and glanced kitty-corner across the wide main street to where the luggage store had once stood. Rather than scrutinizing the current faade-straight lines and too-new reddish brickI envisioned the narrow window filled with a display of attachs and briefcases. The PNC bank logo had replaced the striped sign with the bulls horn logo that had been a part of our family history and identity, but I imagined the old back-lit marquee still there. Back in my hometown of Kalamazoo, Michigan, for my fathers funeral, I saw the downtown that had once meant so much to him through my own lens. What had been scruffy, but vibrant and quirky, now seemed genteel but melancholy. I found it hard to shake the fog of grief. Turning around, I looked down at what remained of the Kalamazoo Mall. Once famous as the first outdoor pedestrian mall in the country, Burdick Street was now reopened to traffic, the fountain and little playground long-since demolished. For Lease signs obscured the emptiness behind many windows. As if stores werent necessary to the downtown economy, leafy trees in early fall color shielded the signage. A narrow street and decorative brick sidewalks had replaced the concrete mall. This morning, the storefronts that once had seemed like magical portals to different worlds were quickly passed by anonymous cars, notwithstanding the citys attempts to spruce up the center of town. A pillar erected at the corner of Burdick and West Michigan Avenue displayed a plaque commemorating the mall and telling its history. I leaned against it as a wave of dizziness swept over 104 me. Memories assaulted me. The angel hair white and red velvet of Santa and Mrs. Claus in the department store window; the gift stores selling tapestries, incense, and dangly earrings from India; the July sidewalk sales I worked as my father yelled to passersby with a megaphone; the Peter Max silk scarf I discovered in a stack of cheap fabrics at J.C. Penney; the patty melts and olive burgers I devoured at the diner. All those family-owned businesses gone. Our family-owned luggage store long gone. After lunch, I traveled farther south on Burdick Street, to the community where my mother and her father before her had grown up. At Balch Street, Grandpa had owned a Sunoco station. Before Grandpa was born, his father had immigrated from the Netherlands and opened a fish market and, eventually, a soda shop on the same site that the station later stood. The retail businesses my family owned didnt begin in the United States. My ancestors owned a paint and colonial goods store in the Netherlands. Before that, they were bakers, shoemakers, and tailorsall trades that foreshadowed retail businesses selling bread, shoes, and clothing. I found the area desolate where the soda shop and then my grandfathers Sunoco Station had been located. The corner where I had spent time with my grandfather was now a case management operation for the disabled. The only building left standing was the unique brick house across the street. I tried to justify away the pain I felt at the loss of the family businesses. After all, change is necessary to life. ### Grandpa was down in the pit, operating on the belly of a customers car. I sat right under the display of road maps, listening to the talk of the men who hung out at the station and eying the machine that popped out fancy green glass bottles of Coke when someone put in a quarter. As usual, I had no quarter. What do you think about that Kennedy, huh? one said. 105 It was Eisenhower who started this with Cuba. I stared out through the glass-paned front door and saw the reverse lettering of Sunoco Oil, followed by A-Z Lubrication, and then, Adrian Zuidweg, Proprietor. The notion of Grandpas name starting with the first and last letters of the alphabet fascinated me. Later, Grandpa took me out behind and showed me the tomato plants he grew back there. Look at them tomaters, he said, bending down and holding up a small green tomato just starting to blush. Kalamazoo muck. He ran his fingers through the moist black soil. For celery and flowers. How come youre growing tomatoes then? I looked at Grandpas mismatched eyes set in his craggy face. I tried to remember which was the blind eyethe blue or the green one. Grandpa pointed to some zinnias on the other side of the door, then showed me the difference between a weed and a tomato plant. My grandfathers daily routine never varied. Early morning, he drove downtown to Michigan News Agency for a paper, then read it over blueberry pancakes Grandma served him. When he had finished the paper, he walked past two houses to his corner service station. Thats what we called it not a gas station because the emphasis was on the service. The boys and one elderly man who worked for Grandpa filled tanks and polished windshields. I didnt want any part of that work, and the gas and oil smell permeating even the coarse paper towels in the tiny restroom made me want to wash my hands when I got home. Whats there to do? Im bored. I rolled my head with practiced drama. Grandpa pulled off his Sunoco cap and smoothed it back down on his thinning gray hair, nodding across Balch Street to the distinctive brick house on the corner. My grandfather built that house. I grew up there. See the light stripe through that dark brick? Thats his signature. He built the Ladies Library Association uptan, too. The house was a little taller than the wood-sided homes on the block, so it impressed me to know Grandpa had grown up there. Where did your parents live? 106 Inside the house. We all lived together. Before Dad died, he turned the fish market into a candy and ice cream shop. He bought a genuine marble countertop during the Depression. I didnt find out until years later that Grandpas father died soon after purchasing the countertop. Then in rapid succession, my grandfathers grandfather and mother died, leaving him alone at age twenty-one. The family business sustained my grandfather and allowed him to marry my grandmother and begin a family. That night, over crispy liver and onions, I announced that I would never work with stinky cars. Too bad Grandpa didnt keep the ice cream store! My mother put down her fork. You could have taken it over when you grew up. Been an entrepreneur. I gave her the fisheye. Im going to be a writer! ### Dad had an unfortunate argument with his boss and came home yelling. A week later, he signed a lease for a one-room office in a corrugated metal building on Lake Street on the east side of Kalamazoo. It had a parking space big enough for a garbage truck. Hun, Im starting it on a shoestring, Dad said one night when his thoughts were off outside our living room, and I was the only person in the room. I looked up from my Dolls of the World coloring book, crayon poised in mid-air, and scrutinized his face. In my mind, I imagined him with an open shoebox containing a few coins, some baseball trading cards, and one shoelace. Janet, whats a good name for the business? He called to Mom in the kitchen. A few days later, he came home with a used garbage truck hed bought from the city. After giving me the tour of it, he let me sit on the sidewalk and give him advice while he painted Industrial Waste Disposal Company on its side in the big, bold letters my second-grade teacher encouraged. Make the l straighter, Daddy. Like a soldier. 107 Within weeks, we settled into our new routine. Until he could hire a man to help, Dad did all the physical work of the business. I liked to ride with him in the cab of the front-loader garbage truck, thrilling when its two automated forks jabbed at the dumpsters like monstrous earwig pincers. Without Dads paycheck coming in, our finances needed to be handled with the attention to detail that only my mother could provide. Mom staked out her spot at a desk shoved into a corner of the basement. Like Mary in Babes in Toyland, she moaned once a week over a stack of bills from that seat of grief. I sat on the floor near Moms desk, under the fluorescent lamp, and wrote little stories on scrap paper. Sometime in the hazy future, I planned to be just like Jo March, with a pet rat, a school of children, and a desk where I could write books. My father had the heart of a small business owner but not always the head for it. He hadnt grown up in a family business the way Grandpa had, or Momor me. Rather than staying put and doing his best, Dad was always looking for a new business deal, and in those early days, more often than not, they werent very successful. When he bought the 20 acres, we drove for hours to take a look at the sleepy woods out in the middle of nowhere. Then my parents talked about the 50 acres and, later, the back 12. He would trade one for another or for a small, failing business, and too often, he didnt come out ahead. Even so, he wouldnt quit. When I wanted to give up ballet because the big girls intimidated me or tried to leave a game because I was losing, he always said, Dont be a quitter. Quitters never get ahead. Nevertheless, Dad was forced to sell the trash business. The story I heard my father tell someone was that a man from the Chicago mob came to Dads office. The guy fingered a knife while he explained to my father why he had to sell to the mans company. Dad accepted the lowball offer. Many years later, I realized that the mob was Dads embellishment, but the storys truth nugget was 108 that the buyer was slicker and rougher than my father. I suspect my father, who lacked investment funds, couldnt face the fact that his first business didnt have enough capital to stay afloat. ### I looked up from my tenth-grade algebra book and stretched my neck. From where I perched on the chair at the little desk in the back room of the luggage store, I could see through the opening onto the sales floor. The black-flecked red indoor-outdoor carpeting, left over from the bar that had closed the year before, was frayed at the seam down the middle. Dad had used the money from the sale of the trash business to buy the company on a land contract from an older couple who were retiring to Florida. At that time, the store had been in a larger, sunlit space with plenty of low display islands for matching sets of pink, midnight blue, or olive green aluminum-framed vinyl luggage. It attracted the wealthiest customers, and they had followed the store when Dad moved it because it was the only luggage and leather goods store in Kalamazoo. Now I noticed that the sets were no longer full; powder blue Ventura was missing a tote bag and a 24 and there was only one piece of white Samsonite left. The main room in the basement had been stacked floor to ceiling with cardboard-boxed suitcases when Dad moved the store. There had been stacks of six to ten cases, but now the pallets to protect the merchandise from flooding were occasionally visible; for many styles and sizes, there was no backstock at all. Farther down the narrow space, up front by the display window and front door, were the glass cases. On the west side, leather handbags hung on wall hooks behind the womens Buxton and Princess Gardner billfolds, cigarette casesboth long and shortleather key cases, and cosmetic bags. On the east side, glass cases held wooden trays of mens billfolds stitched out of genuine top grain cowhide, fandango calf, and Moroccan leather. Behind the cases, mens brief bags and attach cases were stacked sideways like books on shelves, and a wooden library ladder hung from a metal sliding bar to reach the catalog cases on top. 109 I had to peer around the mountain of bills and correspondence on the desk because it towered above my head. Nancy, the full-time salesperson, walked past me to set a train case with a broken handle on the shelf of to do repairs. We hadnt seen Dad in hours. Mom always said Dad had ants in his pants. Staying put in a store was not in my fathers DNA. Nancy, why are all these bills here? Id never seen such a glaring example of an untidy mind. Although Dad ruled our lives, Mom took charge of the house. It had taken her until I was ten to train Dad not to drop cigarette ashes into the bathroom sink, but she ran a pretty organized household. The out-of-control nature of the paperwork alarmed and amazed me. Nancy put on her best rueful expression. Your Dad hates doing that stuff. He hoped Id take it over. Nancy had the same aquiline nose, light brown eyes, and graying hair as my father, but her puppy dog joviality set them apart. Heck, I admit Im not any better at that stuff than he is. I slid open an envelope with my finger. The form letter inside had a big red stamp across it: PAST DUE. I wasnt sure what Dad expected me to do. Hed airily gestured to the pile and suggested I might want to do something with it. However, I had been oblivious to Mom paying the bills at home and had absorbed nothing about the process. They want their money, thats what it means. Why dont you go out on the floor and straighten the billfold trays? I could see the pity on her face. Nancy figured I would rather be with customers than stuck with the pile of bills, but I preferred to hide behind paperwork, avoiding strangers and sneak-reading a book. Be sure the $16 and ups arent mixed into the $10 tray. Nancy lit up a Virginia Slim over by the dirty sink at the top of the stairs. ### 110 My husband turned up the radio volume. Listen! I was standing in our suburban luggage stores deep display window, adjusting fake fall leaves in the Thanksgiving exhibit I was creating. To hear the radio better, I had to jump down and walk toward the center transaction island. Iras body tensed as he strained toward the ceiling speaker. The stock market is tanking! Neither of us had a job outside our long days at the store. We had a baby son and expected the arrival of a baby daughter in a few months. Also, I was a graduate student working on a not-solucrative degree in creative writing. Since we had bought the store from my father, we had moved the luggage store to a larger, sunnier location. We had increased the inventory dramatically to give customers the feeling that we had every suitcase, leather accessory, and related item under one roof. I suppose that we were trying to bring the store back to its condition when my father had purchased it twenty years before. Inventory is money, though, and it meant more bills and a greater need for that bugaboo cash flow. Customers needed to keep buying every single day. They couldnt get scared of the stock market and hold off. A week later, Ira and I went across the street to a restaurant bar. I stirred my Bloody Mary and examined the olives and celery stalk on the plastic sword while Ira talked. I heard writing on the wall and time to get out. I forced myself to focus on the difficult conversation we needed to have. Luggage is changing, you know. I ate the first olive. Ira nodded. The direction its moving in is cheapo stuff from China. I chewed on the second olive. You know I want to write, not stand in the store all day. Although I would be happy continuing to run the office and making the displays. If we cant keep it going, what will you do? I didnt want to increase Iras disappointment, but I loved not having to work for someone else. If I had to have a survival job for writing, let it be where I could be creative and control my schedule. 111 Ira tossed the rest of his drink back. I couldnt stand seeing my father working for my uncle. He should have been the boss. My grandparents owned a candy store on Sutton Place, you know. Really? My grandfather inherited a candy and soda shop from his father! Ira signaled the server to bring us another round. There used to be a candy store on every other corner. Theyre like dinosaurs. With that comment, we both sat in silence until our drinks arrived. ### Although I figured that the doorbell meant another package had been dropped on the doorstep, I clicked save on the story I was revising. With the recent rash of mail thefts in the Phoenix area, I wanted to retrieve the package right away. Besides the Walgreens at the corner and grocery shopping, I hadnt been inside a store for several weeks. Cat food and litter, household supplies, even cosmetics, I ordered through my Amazon Prime account. A day or two later, the package would appear. I was finding it increasingly difficult to find the merchandise I wanted to purchase in local stores. Still, every time I read about a store going out of business, a sickening wave of loss passed through me. As Americans began to shop more and more online, I still couldnt see how fully we would turn our backs on retail until 2020, when quarantine and lockdowns kept so many of us from shopping in already-beleaguered local retail stores. Even after my visit back to Kalamazoo, I stuck to my philosophy that change is necessary. My family had sold what people wanted, and those wants did not remain the same. In 1910, people demanded fresh fish. By 1925, they had enough pocket change for sodas and candy. Americans began to travel more in the 1950s and 1960s, so they required luggage. Now that so many retail businesses have shuttered or are floundering from the COVID-19 pandemic, I see a broader viewpoint. The danger to retail companies is no longer in the product. Retail itself is in danger of extinction. 112 But in 2016, I was still not focused on the gradual decline of retail. The box in front of my door was larger than usual. I couldnt remember what I had ordered, but that wasnt unusual. My front porch had become the setting for a revolving supply of packages. When I sliced the tape with the scissors blade, I saw the suitcase inside--a lightweight molded carry-on with wheels. I checked the packing slip. My daughter had ordered it for herself. Ira and I owned three sets of luggage, but they were from our stores eratoo heavy and clumsy to think of handling without a porters assistance. At the time, the irony of my daughter purchasing a suitcase when we used to be the only store in town for high-quality luggage struck me with the force of another loss. I lifted the new suitcase again, thrilled by its seeming weightlessness. At least this would be more convenient than an oldfashioned train case for bottles and jars as we used to sell. I thought about how the carry-on would make up a bit for how uncomfortable air travel has become. For my first flight, I wore my best dress and Mary Janes, and the stewardess who wore a trim suit and smart little hat pinned a set of gold wings on my chest. After an hour of snacks, I walked down the ramp-stairs feeling like a pampered princess. When I flew to Kalamazoo after my fathers death, carrying my own bags and rushing from one airport gate to another had left me frazzled. Although that first flight was far more enjoyable than the last, ten months into the pandemic has left me craving any kind of travel. I want to spend time in family-owned shops and restaurants in the United States and abroad. I hope they will not be gone when the pandemic is over. 113 Of Ratners Born Daniel Morris Tonight, in Indy after bringing newborn Hannah home to 52nd and Delaware from St. Vincents Hospital off 86th and Ditch (our nurse, Wanda, a Sister, a cross in every room), I light the range, coat the frying pan with an excessive amount of oil, and then place the six frozen Ratners cheese blintzes fold side down (as instructed on the package) in the pan to brown. These are Kosher for Passover blintzes, made, the package says, with special matzo flour. Small world, this late capitalism. Even in Central Indiana we get blintzes from Ratners! Even at the goyish Marsh Supermarket on 86th and Ditch! No one else in this household that now includes three infants, two bewildered parents, and my in-laws is even trying to avoid chametz, though I did wolf the kosher, but breaded, soy chicken patties cold for lunch that 18-month-old Aaron and 30-month-old Isaac didnt touch. In an example of family resemblance by way of diet, not talent, I follow in the footsteps of Isaac B. Singer, whom I used to observe eating his hard roll and black coffee at a cafeteria in South Miami Beach. Am I a vegetarian because I thought the choice would inspire my Yiddishkeit muse to speak to me? Given my responsibilities, I think now more pragmatically about how the need for protein outweighs the strict adherence to Passover rules. For me, certainly not on a low carb diet, just avoiding my ersatz Einstein bagel (with heart healthy butter spread and decaf in the morning) seems sacrifice enough. And so, I eat the faux chicken dipped in the (need I say?) Tref mini plastic container of McDonalds barbeque sauce that accompanies the McNuggets that go with a trip to the Childrens Museum, where I managed 114 not to lose either infant son yesterday. I went to the museum to keep our minds off their mom, who was delivering their baby sister. When it comes to keeping Kosher for Passover, see, I bend the rules. More accurately, I invent my own. I decide, for example, that buying Kosher for Passover soaps and spices and dressings and jellies is simply going overboard. I refuse to line the pockets of Manischewitz, which gouges for items that range in taste and texture from glue to sawdust and yet somehow still everything is 300 calories for a tablespoon serving of salad dressing. If that sounds like a case of a self-hating Jewish commentary, so be it! They charge four dollars for a sugar-spiked coffee cake mix that is really enough for maybe two people at breakfast and takes 45 minutes to stir in their little aluminum pan. A cake mix that I believe should cost no more than 99 cents. I rationalize. I follow the spirit of the Passover laws. It is like being mindful of the Sabbath, even as I shop, drive and check my business email on Saturday. Isnt the focus on spirit, rather than law, a Christian virtue? Once icy pale planks of tough if eggshell thin white dough, the blintzes are now to my surprise frying quite nicely to golden brown in the bubbly hot oil. It is then that the blintzes transform once more into a symbolic image: The Lower East Side blintz. I have, in fact, eaten such storied cheese filled crepes myself, as did my late father, Ernie, before me, at the real places in Brooklyn and the East Village. Im talking the now-defunct Ratners, where my father took my mother, Phyllis, who cant be here in Indy right now because she has dialysis down in Pembroke Pines. Im talking the now-defunct Kiev, where my friend Stephen once had Allen Ginsberg write a poem especially for him on a napkin (Ginsy used Stephens back as a desk). Im talking even more authentic places with Hebrew names I never could pronounce, such as where my friend Norman, another poet, who lives in Cincy, once bumped into Donald, a neighbor from Cincy whom Norman hadnt seen in years. My blintzes are inauthentic, but they resemble the real item. (Of course, the New York blintz is itself a 20th-century re-creation of the humble cigar-shaped blins that for centuries filled the bellies of 115 Ashkenazi Jews of Eastern and Central Europe and Russia before their erasure by Adolf Hitler and Joseph Stalin and World War II). Granted, I used a hell of a lot of oil to get the blintzes to imitate the image in my head of the East Coast version, choosing the heart-unhealthy but potentially more Jewish of the two methods listed on the back of the box. The blintzes fried, but not too much, I offer two with applesauce to George, my Presbyterian but open-minded father-in-law. The blintzes are not so exotic to him as I had predicted (hoped?). It turns out George used to order sweet cheese filled crepes at the IHOP all the time in New Haven when he was a prep school Yalie in the 1950s. Aaron, a year and a half, toddle hops in semi-circles with a piece of a blintz for a while before giving it back to me. To my pleasure, however, Aaron tastes some applesauce with a fork. He has a thing for sauces and dips the ketchup not the fries, the orange French dressing not the iceberg lettuce, the maple flavor icing not the cake donut. Bread products for him are devices to deliver toppings. Bread is to be dropped when the topping has been completely licked off by tongue and teeth on mouth and hands and shirt and table. Aaron will do very well around Passover restrictions in the future, I suspect, as I put on pounds eating off the floor the various crusts left behind from peanut butter sandwiches and pizzas of long ago. I stuff in my mouth the rest of the still warm blintz Aaron rejected, then, sensing Im the only one interested in having more, gobble the last two. That is four (of the six) blintzes in all for me. I have motive. Who but me in this household could decipher the symbolic meaning of my gluttony? Who could know I prepared these blintzes as a private ritual act and consumed them in the same unruly manner on behalf of the memory of my late father, Irwin Walter Morris, among the heavy sons of Brooklyn, gone these 30 plus years, on the day we bring my daughter home, named for my mothers mother, Hannah? Without Ratners Dairy Restaurant, formerly of 138 Delancey Street on the Lower East Side, a case could be made I would not be here. Hannah would not be here. These blintzes now in my belly 116 would still be stacked in their box behind the glass cases in the frozen foods section of the Marsh on 86th and Ditch. It was Ratners, after all, where my father took my mother, Phyllis, on their first date. My mother remembers with some repulsiveness and laughter. Her future husband inhaling the basket of warm onion rolls with loads of butter. God how he loved those famous free rolls with real butter! I am myself daydreaming of those baskets of warm onion rolls and butter when my son Aaron toddles out the front screen door. I wasnt aware of Aarons escape until I hear his shy hi in the darkness from the sidewalk. Thank God he didnt go into the street! It is a dead-end suburban street in a very good midwestern neighborhood, but still! Anything can happen. When I am seven and it is summer, and it is 1969 and Daddy is still a third-grade teacher in a town called Hicksville. And we live on Long Island, and we are a family on Jones Beach. We are near where Daddy was stationed as a Coast Guard attendant in the tower at the drawbridge during World War II (the very tower he pointed out each time we passed it on the way to the beach). And now the riptides of the Atlantic are trying to take my seven-year-old self in for good. The undertow has me until Daddy rather nonchalantly bends his knees, and, like a primitive fisherman, clutches my left arm with his ham hock right hand. He refuses to let me leave this world too early, and now I am here in Indy, belly full and totally blessed. 117 Radio at Night Wm. Anthony Connolly [thrumming] Drowsily dreaming lying in bed, warm sun leaking through the sheer curtain, I awokemy mind struggling with disorientation; where was I? All around me, the room spun in the gloaming, whirling things, places, moments. My body heavy still with sleep, tried to build itself, to reassembly its various parts, its form, that it might give where I was a name. My convolutions, through the reassembling of feet, and thighs; of ribs and lungs, fingertips and shoulder blades, eyelids and ear tips, each conjured from morphing accoutrements; pieces of furniture, smells; light through the curtains, a litany of rooms in which it had one time or another slept and resurrected itself in the midst of the maelstrom dust moats and burgeoning day. And before I could register with my brain any of this, my body catalogues the successive rooms, their bedspreads, the occupants, my brother, then no brother, Man Mr. Nobody, hunching guardian angels resting on bedposts and windowsills; and slowly, it all rose and fell, into meand I thought I heard an answer to a question I had been contemplating lately come from the radio. The signal is a mix of static and clarityI cannot tell if it is me or the radio? And it says: He aint heavy hes my brother Hey sister, go sister, soul sister, go sister. There are spaces too [he aint heavy I miss my dead brother, my dying mother, my sisters, my brother, friends fading dastardly constellations. I try to make sense draw up a shape ] of roaring silence, a drone thrumming deep down in my bones echoing an emptying, a filling up; propinquity, but of what? Not realizing it happens like that, until it has happened, and afterwards drunk on the beauty of it so inexplicable and indescribable. Later, this I write down, my pen digging furrows in a journal. I worry these pagesthese dead me scrolls. I worry sometimes about these pages falling loose, like leaves or garbage, on the street and being found, being found out, found out for what is found there on these fugitive pages. Leaves of lacunae; exegesis of the soul unrolled for consumption by ravenous dogs and gyrovague sojourners who need the sheaths as blankets. The contents of my head. Last utterances until they become the precursory, proem to more. 118 In these pages, a quiet madness, an incessant ache to love and be loved; a continual Chautauqua with some unseen entity who may or may not know what is best for me in matters of chess moves and careers. In this accounting, evidence of a mild case of self-inflicted, self-diagnosed autism: My head full of nothing one day, and then crowded with the scents of flowers not yet found, echoes of tunes not yet heard. Head filled with trapped sparrows. But mostly yearning. Now, the answer on a radio, distant, me lying in bed stunned and sleepy, does not say thisit says, in a flutter in the chest, to keep writing it all down, to keep an ear piqued. Something about gravity and grace, and love, always love. The beauty of the world is a labyrinth we are told, and our ache is making its way through. I rise and go into the study. Ever since childhood, I had been a fugitive. I called Kenny N a nigger when he slashed me across the legs with a hockey stick. My horror and the beating he laid on me, made me a recluse and never again, would I face my darkest fears that I was a dumb creatureI would write them down instead. Ineffable screed. And so, the fugitive needs a record. On the way to my study, I think of pennies (my brain a Pachinko machine). For all those pennies offered and lost, being unable to say exactly what can be discovered here. I wonder now where all those misspent pennies are in wonky stacks smelling of copper and sweat. Or marbles sunk in freshly dug shallow graves. The young friend with a prized cats eye. My salad days of schoolyards and summer holidays; running across winter ice, traversing snowy continents, my footfalls the only trace of my existence. [this is me dreaming] Taking them back, I remember crying to Detroit Rock City, a song about dying young in a car crash. No time to turn. Bass line. I remember a friend, whom I had not seen in weeks, arriving on my doorstep and handing me a gift: a knife. Blood stain Rorschach on dark velvet paisley wallpaper. My brother died that summer, on a stretch of the highway undulating from his drunken eyes, but lived another two decades to haunt himself. He aint heavy hes my brother Hey sister, go sister, soul sister, go sister Oh she loves me, loves me like a rock, my mother Holy Ghost, son and father Back then, I remember defending a gay man against the taunts of my friendsone of the proudest moments of my life. And afterwards, for years, seeing this man and sharing unspoken moments; a nod of the head, a quick hand in the air, a smile as if saying together: do you believe this shit. Such small gifts. It happened long ago, but I can still feel its impact. It rounds up back. He aint heavy hes my brother Back then, I was going to be a star. They all told me this. Silver screen. Sunny days, flat prairies, and sky aquamarine. Running faster than most. Hiking through rows of corn as if sentinels at posts. Gasoline in a pothole filled with rainwater. The taste of it, sweet and dangerous; foreign to my hunger. Dad wrapping strawberries in paper towels, in tin foil and plastic, and ice. A house on the edge of an open field burnished in the sun, burning leaves in some sacrifice. Listening to contraband radio under 119 the sheets at night. Unseen signals from afar riding milk moonlight. Thrumming in the bones. Blinded by the Lightthe shivering unknowns. Her flat stomach, skin milk, honey, soft, the line of hair leading down. Anita. My fingers: The moaning. Anita. Another runner in the night. Making love in forest cathedrals with dawn birdsong and dark basements, with the music loud enough to cover us with dark sides of moons, to give us stairways to heaven, to sing of a farewell to kings. The feel of my bike between my legs as I pedaled, alone, down a stretch of road. Bank Kilimanjaro bent and snowed. Some silicon sister something strong, funky break [pen across the page, across the years, circling back, ink stain] All this comes up and goes down. The order of importance hardly matters. Some can look back upon their lives, see the patterns, and give some calculated shape, some exquisite mathematical proof of our string theory lives. She got down. Shes gonna make it through the night. It is just too hard to tell with me; everything becomes narrative whether or not it belongs to me or fits. It is hard to discern an answer as to why at this age while others bank hours and sell insurance, I find myself in my bathrobe scribbling in a book. Of all the things. How supremely green artists are to the settling of bills and bar tabs, in lining up nests and eggs. But Mommy thats where the fun is I could always charm them. I could always outrun them. No time to turn. Bass line. But these thoughts. Piano chords runnel the road. Gnats worry the mind. Shes gonna make it through the night Lines on a page, page out of mind. He aint heavy hes my brother Hey sister, go sister, soul sister, go sister Oh she loves me, loves me like a rock, my mother Holy Ghost, son and father Come on people now, shine on your brother try to love one another Right Now. It is all down on paper, but when they ask, offering copper, I stutter before saying a word. I plod, shuffle my shoes. How to tell them how much I love them; how much I want them to see the wonder of it all. How much I want them to see the color green in an obscure painting, in my ever-changing moods. My stupefaction. Green means stop, stop being a dumb creature. [pick at the memory s(c)lab with the nib of my fountain pen bleeding purple ink] About how, when I was very young and playing with friends, hoisting mud into the back of someones open station wagon, Id been thrown into a garden shed and locked in there, the house of my dying; oh how I clawed at that stubborn door. The smell of gas, grass clippings, and bird shit. Old wood; thin cracks in the slates, exposing the ferns ablaze in green. That if I wanted to, I could easily place [Inly empty, outward; inward, filling inly] Jesus in there with me, both in me and sitting there on the John Deere riding mower, chewing a cheroot, dangling keys. Want out? 120 About how in a quiet moment on a beach looking out over crystal clear water on a hot morning as a young man, I could see at once the pebbled bottom and the rippling wind on the surface. Mother Mary on a hovering jet ski. Wanna ride? [Inly empty, outward; inward, filling inly] I wish, sometimes, it was easier for me to make sense of my world in words that crawl across the bottom of a TV screen, to make my way in this life, but it is not and maybe I would not like it otherwise. I remember old houses on my paper route. The dogs that chased me, their skulls full of yellow fangs. Scars on my hands from broken rubber bands. Plastic horses on wheels. Simon Says. Avoiding cracks, mothers broken back. I remember cold dark nights walking home, my breath fogged. The crunch of snow. The feel of it beneath my boots. The sky pockmarked with stars. If I put it all in order, maybe one thing would link to another like film reel or chains; like hands holding, breathless in the dark. Panels of paint, impasto. The stutter of dirt roads, drunk, and crazy. But I like the space in between. The cloud of unknowing. Gaps. [Inly empty, outward; inward, filling inly] That I am a mystery to others, but more so to myself. I am a million different people from one day to the next, as are you: For every atom belonging to me as good belongs to you. A mystery why this is what comes to mind is put down in my book, when I contemplate an artists abstract expression of violence, of war. For months, I had been looking for some answers as to why my brother had died and what it meant to me, other than to feel the utter emptiness of his passing, and the lacunae that seemingly formed in his absence, in the absence of what a person of faith might feel for Christ, for God, for their self. And I found myself, as I do when I wander into an art gallery and in that art gallery, being granted a view of what might be, of what ought to be, a view of being locked in, yet free; a vista that is both labyrinth and open field. Of neither the darkest of nights nor the brightest of days. I was drawn to a room-size painting by Cy Twombly. Lepanto. Perhaps because it defies meaning. Or that it hints at other thingsmono-myths, lifecycles, and hope in staving off brutality. Inside, the lacunae itself, the stuff that matters, warbles. Perhaps that. Black holes are found by the nearby wandering warbling lost. Ultimately, it might be because it is a childs drawing, an individuals attempt to wrest uncertainty and chaos to its knees ever so briefly; to say this is what I saw. This is me dreaming. This is me with twelve panels and buckets of paint. Oh she loves me, loves me like a rock, my mother another runner in the night A brothers death. A life of lacunae. Man Mr. Nobody holding shards from smashed China plates. 121 [lepanto] Cy Twombly, American, 1928- , Lepanto 1-12, 2001; acrylic, crayon, and graphite; 12 times 85 x 122 inches; Udo and Anette Brandhorst Collection (Brandhorst Museum, Munich, Germany) So get up close, as near as you can get without setting off alarms, you begin to see, perhaps feel So when I say, that if you move in real close to Cy Twomblys Lepanto, move extremely close to the first of the twelve panels and see in the upper right hand corner a sliver of green, and that the green impasto is God, you would just have to take my word for it. For what is found there is what is found in all of usmystery, and too much love sometimes to contain, and radio, radio at night. Unseen signals from afar. Blinded By the Light. Solar eclipses and God blind us. Looking directly means not seeing at all, it is blurry and scary. The only way is through; we can see the moon cover the sun, God incarnated, only by projectiononto boxes, into music, off walls, and in peoples faces. Through these slivers and memories, through witnessing this, this is how I come to stand before a daub of paint and see the deus ex machina. Someone has found this, and this is what is found there Were one, but were not the same We get to Someone has razed the house and hung its walls vandalized by a tormented resident. Standing back affronted, but scrutinizing the display nevertheless, twelve panels come into view as if roof, hallways, furniture, and floors of this dwelling has been shunted. These are walls, scrawled upon and dirtied by a frenzied hand. These are projections, gargantuan biographical Rorschach blots, of a mind swarming with bees. To the dwarfed witness scanning this work, it appears a suspended miasma, partly due to it immensity, but also because of violent and chaotic streaks, smudges and smears of strange tonality. One wonders if the gallery roof has leaked, or crazed activists have broken in to defile the canvases with water and lye. Splotches of red and black cankers arise to adjusted sight as if open wounds from the predominately bone color of the panels. Closer, paint drains like horror movie blood streaking over stark crimson and tangerine flash splattered stars; light Aegean blue dimmed with an underpainting of skim milk white obfuscates like smoke; over-painted dark lines borne perhaps from a graffiti artists bold black Sharpie riddles canvas after canvas and conjures an armada in an odd, orderly formation being savaged. Given all this, still the human eye here is a weakened instrument. Drawing near, fearing as much the clichd moths demise, and examining the first of the twelve panels, there along the upper right-hand corner, lays a sliver of Kelly green, nothing more than a cleft of paint. (Out of eyeshot: akin to Icarus scissor-kicking into Brueghels drink or the JonBenet crawl beneath Larry King; a symphonys conductor, culling a four-beat measure, moving the baton in the sign of the cross). This is a green fissure, an identifying stamp, perhaps from the resident of this dismantled house. This green streak, blooming as it does amid the immensitys chaos, seems careful and full of intention. It says it was madness in here, but there was still presence of mind; that in all the hues of brutality, hope remains that something anew flowers from catastrophe. The color never reappears. As one works their way through Lepanto, the chosen palette takes on an organizational pattern arranged in 122 two-three-three sequences throughout the twelve parts. Each panel represents a particular, shall we say, camera angle: birds eye, mid-shot, panoramic. While these angles are repetitive, here color is king. The repetition of color gives Lepanto voice. Sometimes surd, sometimes susurrate, this voice all the while cants: History repeats itself. As one becomes more accustomed to the work, like slowly regaining eyesight in bright sun, Cy Twomblys Lepanto impacts like a grotesque triune, consisting of three panels in each section, segued by three sparrows-eye-view panels. In each section, the story is repeated by way of signifying colors. In this way, Lepanto is a twelve-part loop of Acrylic, wax crayon and graphite grouped in three repetitive chapters. If folded back in on itself, the resulting structure would be a mausoleum to war, an ossuary of violent bones. In these times of discordant moral rectitude, some might then secure materials to reattach a roof, establish hallways, bearing beams, and install a suitable door to be sealedforever pleading ignorance to the drone from within its walls. The installation does depict horror; this is true. It does so by addressing our fragmentary and vapid attention span, borrowing conventionsthe shaky camera Dogma 85 editsfrom movie houses, home to our most passive form of numbing inoculation. But, for that green, that wondrous green daub of hope. It is telling us something, if we focus, if we slow. To ignore this detail, to mock it or blink to dismiss it is to assist the sextons with our own burial plots. We cannot walk past without pause. First, Lepanto is the story of a 16th-century naval battle between Turkish imperialists and Christian isolationists, delineating in history the Ottoman Empires demise. The alliance of Papal States, coupled by Spanish and Venetian might helped to vanquish the Turks. Eyewitness accounts of the October 1571 battle said the waters turned red with blood, smoke obscured the sun, and ships burned gold and crimson against the night sky. The installation reads like a film reel. The work appears rudimentary and haphazard, perhaps even stained or damaged from afar, but closer examination shows the genius of composition in re-creating the conflagrations of combat at sea. This is a tortured soul writ large, circular, and rhythmic. In one respect, the vessels and oars Twombly creates harken back, pay homage to the Lascaux cave paintings. Those Paleolithic paintingsfound in the 1940 by a group of young boys and their scampering dog in southern Francewere drawn on the walls of underground caves and were characteristically large and crude. Moving forward through time, the Lepanto painter takes on another watershed of art. The painting drippings and blobs found in most of the panels might find progeny in the likes of Jackson Pollock and Willem de Kooning, although Twomblys hand appears less taut, more childlike. The impasto, where brush strokes are visible, suggests Twomblys signature of departure from those 1940s1950s abstract expressionists, whose strokes were more aerial in orchestration than grounded upon surface. In another respect, the recent past is evoked here too. Jean-Michel Basquiat, New Yorks art wunderkind who died in the 1980s, could have easily scrawled Twomblys boats on the walls of lofts in the Meat Packing District. In a way the artist uses the history of his medium, pulling the viewer from 15,000 BC through to modern times, to illustrate while an idiom changes, what it speaks of does not. An age sharpens or dulls a work of art by its implications. Whatever is derived in service of this goal, the impact is original and revelatory. Lepanto, like Homers Iliad, speaks of a point of history, but also voices contemporary concerns. Both are implicated by what the viewer brings to the work of art. Art instructs outside of time. A viewers experience serves to recreate the initial impetus, the creative response to an external stimulus. Since this is a nation at war, to say Lepanto is a direct dialogue with the U.S. citizenry is not overstating the case. It was created in the year America was attacked. It does strike me as peculiar yet universal. Neither ugly nor beautiful; 123 neither a relict nor prophesy. It seems ancient in its song cycle. Therefore, those mad bees might just be inside us all. This bedraggled house might be our very own. Those burning ships, our flotilla far from these shores. But of course, not everyone can live with this, to live within those walls or even cultivate an understanding of such a structure. Abstractions tend to speak a highly individualized lingua franca. What one hears might not be what the other hearsor sees. The soldier will invariably be drawn to Twomblys panels of destruction as if in the inertia of duty. The engineer might be inquisitively drawn to the vessel formation and calculate the number of oarsmen to gauge propulsion. Those seeking the substance of things hoped for might be drawn to open spaces or skeins of green. In this light, Lepanto can be approached in two ways: seeing is believing or believing is seeing. Abstract art is more about the viewer than what is being viewed. This meaning, this projection finds its source in personal psychology, undoubtedly, my brother is dead, but also surely within the psychosis of a society this is a culture of violence. Another runner in the night [violence] First coined by Jungian Marie-Louise von Franz in her 1978 volume, Projection and Re-Collection in Jungian Psychology projection is the process by which a mind, faced with perceptions about itself that it finds unapproachable firsthand, buries these perceptions in the unconscious. The unconscious, then, being indisposed to such reticence, finds some other way of dealing with the material. Slyly it then projects this repressed perception onto some external person, thing, country; it could be a wall in a cave, a wall in a suburban home, foreign power, a canvas to be hung in a gallery, the words found in an essay. By externalizing, the mind can then address the material in a disguised form of objectivity, resulting in either some overt form of action; this might manifest itself in homophobia, racism, or warmongering. Fittingly, Lepanto, composed in 2001, came in an era of heightened fear, of terrorists, and extraordinary carnage. A time when foes are found by length of beard; we finger enemies by color of eyes or how many times they fall to their knees. In Twomblys retelling of this historical battle, empires puff up their chests and pay for their hubris; witnesses say the sea turned to blood; the point of view changes, but the story remains the same. Nothing remains that violence cannot put asunder until it defiantly grows to battle anew. Violence is always responded to with violence. When terror hit American soil, force was dispatched to its supposed source. But fat with vengeance and a penchant for half-truths, the U.S. government continued its push to ferret out those who would do her harm. With zealotry, it proffered Black or white stories about the gray world. The administration drew its sword on false charges, and continues, to this day, to torment its denizens with packaged rationale, which rains like so many veils. It is an administration the Ottomans would have been proud of, an administration after its own deceitful heart. The cycle never ends. Death is supremely victorious. Truth is its first victim upon which the darkest curtain falls. It is perhaps important for a viewer to concentrate on the installation, paying close attention to panel number six. This panel, this wall of the house dismantled, is cleaved. There is a duality here, at the very least, a sense of before, and aftera demarcation of sorts. Moving left to right, a third of the canvas is distant and foggy until like a sudden storm cloud the right portion of this scene intrudes. 124 Dark blood and sores are exposed; yellow flourishes and Blackness reigns in a shroud of paint. Viewers might be drawn here, swaying side to side imperceptibly, trying to come to grips with this marked implication. There is a time before, just before the veil comes down, and then it is through the dripping darkness we go, until as Lepanto shows, we circle back and find ourselves once again on the doorstep of this strange house. If only we stopped to contemplate the real green. But it is just a painting, albeit a large one, composed by an old man who does not even live on this soil. He aint heavy hes my brother Hey sister, go sister, soul sister, go sister Oh she loves me, loves me like a rock, my mother Holy Ghost, son and father Come on people now, shine on your brother Everybody get together Try to love one another right now, & forever. Were one, but were not the same We get to [trust] Lepanto then becomes an ironic entity of an age, an age the CIA could describe as a wilderness of mirrors. This is the term used for when operatives lie, and their lies are piled upon lies making the truth all but inaccessible for its wild thicket lair. Everywhere we turn, reflection upon reflection produces discombobulation and nausea. Here, truth no longer matters. Here, what you see is what you get: Yourself staring back. Oh, then it all must be okay. I trust that person. Of course, who supplies and polishes these reflections? We do; we, the people unwilling to speak of what some see in the horrid canvases hung for us nightly and broadcast. To say the house first must be dismantled, put on display for others to see. There must be blood and explosions; there must be uncertainty and carnage. There must be a chronicle of torment, a drone in the skull. Still, it is open to interpretation, but at least what is viewed, ugly and scary, will be more than our own faade. It is a viewing inside that Huber hive of the soul, where masks are removed. The personal unmasking that Lepanto guides, answers these queries with devils, disturbances and, for some, deliverance. It depends if one notices Twomblys deus ex machina, that sliver of green. It depends if one listens to static for slivers of silence. [Inly empty, outward; inward, filling inly] So when I ask, when I plead on my knees to come closer, to get closer to anyone, to seek in the eyes of others that impasto, a little slivered greenyoull do it, because when my brother died, all I saw were holes, and when you come to know that inly, there are no distinctions; the lacunae is filled by others and you will see and know, we are all a little drowsy, mad, and miraculous listening to radio at night. 125 Or in the immortal fiat of Chrissie Hynde (Mother Mary on a jet ski): Now the reason were here as man and woman, is to love each other. Take care of each other Everyone has green eyes, sparrows trapped inside ... Carry each other. Carry each other. Round and round it goes where it stops no one knows. Save that cleft of green. Green means stop. Save dispatches from afar, save the secret scar. Inly empty, outward; inward, filling inly & I say you. 126 Life, When Its All Ruin Michelle Moyd I. Immersion There were times during the pandemic that I allowed myself to feel. I had feelings, of course. Lots of them. So much rage. Dismay. Disappointment, too, in a society hell-bent on destroying and discarding the lives of Black people, Indigenous people, poor people, queer and trans people, immigrants, disabled people. So much fear and worry for distant relatives, elderly neighbors, immuno-compromised friends. So much self-directed anger at my belated recognition, once again, that I too am just a worker. Given my job security as a tenured professor, I had rarely thought about its potential precarity. The prospect of the pandemic destroying universities, my job thereby becoming an unnecessary luxury, descended upon me in a new way, surpassing any of the other times I had considered the inconceivable. I too can lose my job. What if I lose my job? If I do, I will become a different kind of worker. What would I do? What could I do? How can I care if I dont have care? Fleetingly, beyond those feelings, I sometimes let myself feel wonder. One of these pandemic moments replays in my mind. A touchstone, a glimpse of beauty and possibility enabled by the specific dark coziness of that day early in the pandemic. In my mind, the moment evokes cinema. In real digital life, its a still photo. My daughter twirls on the dining room hardwood, holding her precious well-loved blankie loosely in her hand. She twirls. I watch her from the kitchen, entranced. She is barefoot, looking down, lithe, elegant, the ratty heirloom blanket following her, flowing. Her flowered fuchsia leggings are paired with a white long-sleeved t-shirt emblazoned with a sparkly gold and pink unicorn. She loves pink. I post the photo on Facebook, and my dancer-dance critic-anthropologist friend remarks that she, my daughter, could be a youthful Judith Jamison. She says the image is healing. I think so too. I am in my kitchen, preparing fresh food purchased from the upstart new farmers market in town, the Peoples Cooperative Market. 150 The citys long-standing market couldnt figure out how to dislodge a white nationalist from its midst. Its a long story, but also the same story that one might Ellen Wu, Ethos of New Peoples Market Focuses on Food Justice, Mutual Aid, Limestone Post, April 16, 2020, https://www.limestonepostmagazine.com/peoples-market-ethos-focuses-on-foodjustice-mutual-aid/; Ellen Wu, Bloomington 2019: The Year of the Farmers Market Controversy, Limestone Post, Dec. 20, 2019, https://www.limestonepostmagazine.com/bloomington-2019-year-offarmers-market-controversy/. 150 127 find in any number of predominantly white, liberal midwestern college towns. The Peoples Cooperative Market is the counternarrative and antidote, and preparing food purchased from its vendors makes me feel like Im doing something right. While preparing food, I listen to music. Not just through my earbuds while walking our dog, but through a speaker, in the kitchen, for all of us to hear. I dont do this often enough, I say to myself. Because if I did, I would have to feel and acknowledge the wonder of immersion in the sounds, the lyrics, the grooves. And someone might see my immersion and ask me about it. Cant have that. Im too busy being stoic, or angry, or sad. I resist joy. Still, occasionally, I treat myself to the immersion. I treat myself to feeling more than my poker face gives. My daughter immerses herself too, dancing. Or maybe I just remember her dancing. Maybe she was just spinning around for fun, playing with music. I recognize that we are both moved by the music. I share. II. Life The soundtrack is Frank Oceans Pink and White. 151 On repeat in my own small world, on headphones, it haunted, comforted, moved me for reasons I still cant fully explain. After countless listens, it is a song that sends me into myself, nostalgic, feeling loss but also the warmth of beloved memories. A short violin flurry, a flourish, introduces the song. Then, simple piano chords and their punctuating repeat, lilting, building, receding. The bass line is regular, but also produces a playful feel, like a child skipping, ambling. Or ocean waves lapping. The lyrics come in. Thats the way every day goes, every time weve no control. If the sky is pink and white. If the ground is black and yellow. Its the same way you showed me. Oceans poetry evokes a strange skyscape (pink and white), a believable landscape (black and yellow). Its the same way you showed me. An incantation throughout the song that on this day tells me we will be alright. Another two verses follow, gestures, north-south geographies, atmosphere, and an unequivocal statement about love, trust, and support during disaster. The way it is, were on land So Im someone to hold true Frank Ocean, Pink + White, Blonde, Apple Music, 2016, audio file, https://www.youtube.com/watch?v=uzS3WG6__G4. 151 128 Keep you cool in this good life Wont let you down when its all ruined And then, a bittersweet chorus. You showed me love, glory from above, regard my dear, its all downhill from here. Oceans song names love from another time, love lost, as well as care that taught lessons, showed glory, kept him alive. Perhaps not maternal love, but this may be why the song gets into my fearful soul during that uncertain time. III. In the wake of a hurricane In the wake of a hurricane Dark skin of a summer shade Nosedive in the flood lines Tall tower of milk crates Its the same way you showed me Cannonball off the porch side Older kids trying off the roof Its the same way you showed me 152 The sound is ethereal, the lyrics recalling childrens play and swimming pools. The steady bass line and recurring piano accents push the song along, insistent. A strumming guitar comes in, breezily, and the song takes on a new feel, lightness, movement. At the end, the multi-tracked background voice of Beyonc sings take it easy, lifting, soaring, taking the song ever skyward. If the sky is pink and white. Remember life, remember how it was The final lines of the song shout out to friends, family, cigarettes, transgressions, tragedy, commodity. Immersion in nostalgia for an ominous time, but still a time of connection. Fond memories backlit by menace. Bitch, I might like immortality, Ocean sings, and I raise my eyebrows, nod, smile. IV. When its all ruin I made this memory at the start of the pandemic lockdown. I looked up the date of the memory, and I was surprised to learn that it hadnt happened later in the summer or fall. From my current vantage point, it already felt like a much older memory. Technically, it was spring, but the cold temperatures and dreary rain suggested winter hanging on interminably. Fueled by many sources, my In a 2012 interview, Ocean described a childhood memory of the aftermath of flooding in New Orleans using nearly the exact same language and imagery. See Matthew Trammell, Soul Caliber: Frank Ocean, Wax Poetics, 50 (Winter 2012): 82. 152 129 multidimensional anger permitted little space for feeling otherwise. A few months later, I would write about the cruel system that refuses to care for people in a time of emergency long in the making, urgent in its deadliness. I would write about the cruelty and selfishness that animates a significant portion of this countrys population. I would speak to administrators, colleagues, and family about the cruelty of expecting productivity in a time of ruin. 153 It didnt matter. I had to work, my partner had to work, and we cared for our child at home while working. For a time, this felt like the worst thing. But in truth, the worst things never touched us. We had jobs. We didnt have to worry about how to care for our child. How to keep her safe from the unending dangers afoot in the United States in 2020. We worried anyway. Ahmaud Arbery and Breonna Taylor had already been murdered, though most of us didnt know it yet. George Floyd and Dreasjon Reed were still alive. So many others were still alive. Over the next few months, the worst things happened to so many people. Hundreds, thousands, hundreds of thousands died of COVID-19. Hundreds of thousands took to the streets to protest the police murders of Taylor, Floyd, Reed, and others. Thousands were arrested, brutalized, gassed, harassed for protesting. We watched Watchmen and Lovecraft Country and saw the horrors of history on new filmscapes, with new eyes. Frank Ocean grew up and lived in New Orleans until Hurricane Katrina disrupted his life as a college student and destroyed his recording studio. Pink and White recalls a time before disaster, as well as survival in its aftermath. 154 When he sings in the wake of a hurricane, listeners glimpse possibilities beyond the catastrophe. Nostalgia shades his poetry, warming me, just as the sun warms the youthful inhabitants of his lyrics. V. Pink and White Over a year later, memories of survival, domestic closeness, and simple truths learned during a year of unacknowledged grief intermingle with the current fantasy of the catastrophes end. My daughter still loves her blanket. It was once white, once my underused baby blanket, stored lovingly in my parents attic until my daughter was born, then passed along as an heirloom. Now it is gray with the years of my daughters fierce love and laundering. Gray like much of my hair. Gray like the rain that day. She still loves pink despite my past futile efforts to stop her from loving pink. I refused pink for her as an infant, and now its all she wants. My feminism includes pink now. Michelle Moyd, You Need Devotion: A Syllabus, Digital Feminist Collective blog, Sept. 8, 2020, https://digitalfeministcollective.net/index.php/2020/08/28/you-need-devotion-a-syllabus/ 154 About Hurricane Katrina, Ocean told an interviewer, I cant credit it with too much. I can credit it with being the reason I moved to L.A. Ultimately, the reason Im successful might be attributed to Katrina. I dont think I would have moved if it hadnt been for that storm, and I dont think Id have been successful if Id stayed in New Orleans. See Trammell, Soul Caliber, 82. 153 130 Her favorite color and her beloved blanket, Frank Oceans poetry. More than a year later, I still love Pink and White. I still hear the catastrophe, the recovery, the potential in the song, and that allows me to see it in our lives. The memory of that day, my daughter twirling, the care of preparing food, the beginning of a new visceral experience of care in its many dimensions, as work, as life. In Pink and White, I feel it all. Acknowledgements I would like to thank Anya Peterson Royce for her wonderful comments on a draft of this essay. My partner, Scot Wright, also read and commented on the essay, and edited the photograph that accompanies it. I am grateful to Ross Gay for a timely conversation that helped me finish it, and to Maria Hamilton Abegunde for inspiration and encouragement. And finally, many thanks to Wes Bishop for inviting me to contribute to The North Meridian Review, and for his generous editorial work. I dedicate this essay to recently deceased family and friends: Ada Moyd, James A. Wilson, Jr. Denise E. Brown, and Theodore Douglas Wilson. And to my parents Henry Louis Moyd and Heather Ann Moyd for their uncommon strength, and for teaching me to feel through music. 131 Bibliography Moyd, Michelle. You Need Devotion: A Syllabus. Digital Feminist Collective blog, Sept. 8, 2020. Ocean, Frank. Pink + White. Blonde. Apple Music, 2016. audio file. https://www.youtube.com/watch?v=uzS3WG6__G4. Trammell, Matthew. Soul Caliber: Frank Ocean. Wax Poetics 50 (Winter 2012): 8088. Wu, Ellen. Ethos of New Peoples Market Focuses on Food Justice, Mutual Aid. Limestone Post, April 16, 2020. Wu, Ellen. Bloomington 2019: The Year of the Farmers Market Controversy. Limestone Post, Dec. 20, 2019. 132 IV. POETRY 133 Introduction: Ricardo Quintana-Vallejo, PhD. The North Meridian Review sought poetry that takes a snapshot of the grief, uncertainty, and withdrawal that characterized the year 2020. At a time where the comfort and expectations of routine became a source of anxiety, we turned to poetry for scrutiny and respite. We were fortunate to receive poems that depict a range of experiences and sensations: the sense of annoyance in the early days of the pandemic, when we thought that we would be back in our schools and workplaces by the end of summer; the reshaping of our everyday lives because of homeschooling and home-office; the anguish and chaos faced by healthcare workers; the echoes of other viral pandemics such as HIV; and the upheaval of our interactions and relationships, embraces given through Zoom. Finally, several poems in this collection address our shared global anxiety. Discourses of globalization imagine our existence as digital beings, hyperconnected to each other internationally, watching the same videos and films, conversing as if we were in the same room, despite the geographical realities in which our bodies dwell. Yet no other event in recent history can foreground how corporeal we really are: a strain of crown-shaped RNA has overhauled many of humanitys mundane and momentous practices, from how we work and shop to how we get married and celebrate graduations. Unfortunately, our realization of global bodily interdependence also bred racist and xenophobic images and sentiments in the poetry we received. I rejected every single poem about bigotry and hate because our objective in collecting these poems is to enable connection, catharsis, and empathy. 134 We gave preference to poets from the Midwest in accordance with the journals obligation to serve its community and region. However, we included poems from all over the United States and abroad, including Mexico and Australia, to provide multifaceted perspectives on an event that affects humankind. This collection includes the esteemed work of two poets, David Estringel and Lisa Bullard. Their poems are reprinted here for accuracy and were previously published online. Although not about the COVID-19 pandemic, they are a valuable addition to this issue. 135 Tina Schumann is a Pushcart nominated poet and the author of three poetry collections, Praising the Paradox (Red Hen Press, 2019), which was a finalist in the National Poetry Series, Four Way Books Intro Prize, and the Julie Suk Award; Requiem. A Patrimony of Fugues (Diode Editions, 2017), winner of the Diode Editions Chapbook Competition; and As If (Parlor City Press, 2010), which was awarded the Stephen Dunn Poetry Prize. She is editor of the IPPY awardwinning anthology Two Countries. U.S. Daughters and Sons of Immigrant Parents (Red Hen, 2017.) Here work received the 2009 American Poet Prize from the American Poetry Journal, finalist status in the Terrain.org annual poetry contest, and honorable mentions in The Atlantic, Crab Creek Review and The Allen Ginsberg Award. She is a poetry editor with Wandering Aengus Press, and her poems have appeared widely since 1999, including The American Journal of Poetry, Ascent, Cimarron Review, Michigan Quarterly Review, Midwest Quarterly, Nimrod, Parabola, Palabra, Poetry Daily, Rattle, Verse Daily, and read on NPRs The Writers Almanac. www.tinaschumann.com Isolation Affirmation I make more of these moments than perhaps I should. Last night in a friends garden, over a dinner of take-out curry and saag, the last warm air of summer cushioning our conversation, we spoke of long-ago travel; motorcycle tours over the Dolomites, sailing cruises to Catalina, hitchhiking in Spain. Because we had been sequestered and forced to face ourselves for too long the mere talk of travel felt rebellious, thrilling in a way it hadnt since our teens. We were rule breakers. Throwing our masks into the air behind us and blowing down the open road. While the ice cream man chimed his bells throughout the neighborhood, we looked into each other's faces and reaffirmed the facts of our past saying Wed been there. Wed done that. 136 October Lately, its been like Groundhog Day around here; same thoughts, same steel whistle of the kettle, same slow pulse of another smoky sunset. Still, people really are trying what with their chipped toothed jack-o-lanterns crouched on the front porch and gauzy ghouls peeking out the screen door. They are trying to say hello to this misstep of a season contained within this misstep of a year. This close to the end of it all we reach out for the usual and the comfort of a childhood mask. As if the scare tactics of reality were not enough. We want the kind of fear we can decorate and fold away in a box the next day. Now that we are all bi-polar and understatements abound its a trick of the mind to keep going a treat to be delusional together. Thats OK. Lets be something less capricious than the garden-variety delusional; you buy the waxy candy bars in their little coffins of colorful paper, and Ill screw in the red lightbulb over the front door. Someone is bound to ring our bell in their chosen disguise just begging for something completely different. 137 Self-Portrait as Shut-in Even the summer air seems carotid with disease. Invisible though it is. The season is no invitation, but a rude seducer. Not a caress, but a diabolic consequence. It gives you pause, and then another pause and another. Better to not venture. Dont speak. Dont blink. Just dont. Streetlights cast dystopian beams over cars and empty bleachers. It floods this suburban dream. Like a bad cop in a windowless room it demands Where are you from? Who sent you here? Show us your papers. The words are muffled, of course, as every mouth is wrapped in gauze. The radio is no help, not the news or the mail. Those daily standbys only reinforce the rules: dont touch your face, stand six feet apart, try to make your eyes look like a smile. Now, every love song is overwrought. Ridiculous with ardor. Every old impulse a broken notion; unattainable, pass, a joke you forgot was a joke. Nature is no longer free. Public spaces? Not so much. You feel yourself 138 an imposter, escapee, out-patient on the lam and that old song keeps running through your head Got nowhere to run to baby, nowhere to hide 139 Mariana Mcdonald is a poet, writer, scientist, and activist. Her work has appeared in numerous publications, including poetry in Crab Orchard Review, Lunch Ticket, and the New Verse News; fiction in So to Speak and Cobalt; and creative nonfiction in Longridge Review and HerStry. She co-authored, with Margaret Randall, Dominga Rescues the Flag (Two Wings Press, 2019) about Black Puerto Rican heroine Dominga de la Cruz. Mcdonald lives in Atlanta. Sleepless Hypnogogia: Not a place, or ancient myth, but endless miles of highway the mind travels on the road to sleep. The scenery is neon clouds, fluorescent fields, and glowing craters. The jaunt was now and then before all this. In coronatimes, 140 its nightly. Sometimes Im almost there, at my yearned-for destination blissful oblivion when a thought zips by like a pebble on the windshield, and I swerve awake, suddenly in a traffic jam where nothing moves, the hours pass, and Im stalled in hypnogogia again. 141 Against Reopening Brookhaven, Georgia. May 2020 Brookhaven is the city I had thought of, small but bustling, vibrant, young and on the way to great adventures. Just the size of that days virus deaths across the country, in the thousandsfifty-three, a number quite unsettling. I argued that the virus is still raging. Look, as many people dead as all of your own city, cant you see the danger? People want to open up. I get it. But Ill refrain from outings for my safety, all our safety. That was two weeks back. Today, the numbers at Johns Creek, nearly ninety thousand people gone. Soon it will be Macons hundred-fifty. How I fear the terrible road to Atlanta! 142 It makes me think It makes me think of AIDS. The blundering, the slowness. Denials and neglect and ravaged bodies. Toxo in the brain and purple lesions. Morgues heaped with Black corpses. It seems like that yet different. Omnipresent in the stars and skies. It makes me think we have to rise again, angry, fearless, to make a better history, to leave better memories for the earth. 143 Patricia Thrushart has published three books, Little Girl against the Wall (Quimby, Pickford & Cheshire Publishers, 2009), Yin and Yang (Quimby, Pickford & Cheshire Publishers, 2017), and Sanctity: Poems from Northern Appalachia (Quimby, Pickford & Cheshire Publishers, 2020). Her work appears regularly in the Watershed Journal, a regional literary magazine of Northwestern Pennsylvania, and on the websites Dark Horse Appalachia and North/South Appalachia. Her poems have been published in Tiny Seed, Clarion Universitys Tobeco, the Avocet, Still Point Arts Quarterly, the Pittsburgh Post-Gazette, Feminine Collective, Curating Alexandria, High Shelf Press, and included in the Northern Appalachia Review. Her first historical nonfiction book, Cursed: The Story of Marion Alsobrook Stahlman, will be published in October 2021 by Adelaide Books. Grocery shopping Mask on, I learn how much I rely on the lower half of my face to make amends my cart in the way of the flour, my long pause in front of the tuna, going the wrong way. Gone is the smile that says: Im friendly! Im sorry! I wear a covering below my eyes behind fogged glasses that dont emote the way glossy lips would. Im instantly inscrutable, suspected of hoarding flour, being too choosy about tuna and snooty too with a high-end car that opens the trunk when I wave my foot below the latch. Groceries in the trunk, I go home to the only ones who now see the intimacy of my naked mouth. 144 Masked I start sewing on Passion Friday, the silver needle piercing a bolt of black cotton woven tight, tripled, cut and tucked to shroud the nose, the mouth; bound with ties to draw the fabric close, like a winding-sheet. I sew, the needle like a thorn, the fabric bunching and smoothing under the glare of machine light, the hum of bobbin and thread, taking tiny stitches until the mask is done. I put it on the face I shouldnt touch, hiding the sorrow I know it shows. 145 DS Maolalai has been nominated four times for Best of the Net and three times for the Pushcart Prize. His poetry has been released in two collections, Love Is Breaking Plates in the Garden (Encircle Press, 2016) and Sad Havoc among the Birds (Turas Press, 2019) His new moustache we met him up near stoneybatter, when he was only a few days home, just after a month-long binge, he said, in sligo in a house by the countryside mountains, where hed lived when the covid had hit. hed been cycling when we saw him toward the stoneybatter markets, kicking speed and wearing a rugged moustache, 146 and he skidded a loop through dust and around light traffic and stopped by the courthouse to talk. and we had been out a minute easy, walking the dog and picking up our groceries and fish grew hot by the wine and stained our knees with sunshine, sweating through thin plastic shopping bags to the seaside smell of fresh and dribbled piss. and he told us about his problems getting work since hed been back and his problems getting dole, or any sort of covid payment, his problems 147 meeting girls right now and meeting his friends our friends for a drink. he talked a good 30 minutes it was unusual hed been in paris and australia and not talked so much. eventually we made excuses the dog needed to be fed our masks were sweating us and went on. he must have been very lonely to want to talk so much. afterward, crossing the road, we looked back and he was gone, stitching his wheels into traffic, dragging his sweating body and his rugged new moustache. 148 Xiaoly Li is a poet, photographer and computer engineer who lives in Massachusetts. Prior to writing poetry, she published stories in a selection of Chinese newspapers. Her photography, which has been shown and sold in galleries in Boston, often accompanies her poems. Her poetry is forthcoming or has recently appeared in Spillway, American Journal of Poetry, PANK, Atlanta Review, Chautauqua, Rhino, Cold Mountain Review, J Journal, and elsewhere. She has been nominated for Best of the Net twice, Best New Poets, and a Pushcart Prize. Xiaoly received her Ph.D. in electrical engineering from Worcester Polytechnic Institute and her Masters Degree in computer science and engineering from Tsinghua University in China. Far and Near Red Planet hums millions of miles away as we expand our wings deep into space. Yet we are hiding. Hiding from viruses that are invisible and older than us. The world is trembling as we cut down forests, boil the wild with our hot pot. Now virions sneak into our cities, stifle our breathing. In this hazy morning, winter jasmine blooms spring, a pair of robins hop in the backyard grass. And so bright and big is the moon awoken and humbled, I want to touch it with my sanitized hands. 149 How Corona Evolves or Makes Us Evolve, or We Have to Evolve Together video chat with Mom on a hazy snowy day in March Are you all staying home now? Yes, our poetry group meets online. We have five hundred people meditating twice a day at home at the same time. And we only take walks in our neighborhood. Dont go out, just do Taichi in your backyard. We walk the opposite side of the street when people pass by. China is the safest place now; do you go out? We still stay at home. A manager calls every day to check our temperatures. We need to persist. What are you eating, do you get things you need? Rice-millet porridge, walnuts, Brazil nuts, pine nuts, and a Fuji apple Dont go to stores. These were home-delivered and left at our front door. Soak vegetables in soda water to keep them clean. Oh, good idea, will try How is our granddaughter in the hot spot of NYC? We have pleaded and shes not coming back. She said she can concentrate better on the work over there and prevent cross-contaminating us. And she wants to read more books in the evening. Does she stay at home and learn to cook herself? She works from home but jogs along the river. And we told her to make ginger, lemon, and honey tea. Sometimes we shop online for her to grab a delivery time slot. She used to dine out. Look at this photo what she has made last night! Wow, very impressive. Roasted chop, red peppers and asparagus, fresh colored and shining. Do tell her not to go out and to exercise at home. We cant keep warning her. She wants to hear lifes other stories. 150 Steven Luria Ablon, poet and adult and child psychoanalyst, teaches child psychiatry at Massachusetts General Hospital and publishes widely in academic journals. His poems have appeared in numerous anthologies and magazines such as the Brooklyn Review, Ploughshares, and the Princeton Arts Review. He has published five full collections of poetry including Tornado Weather (Mellen Poetry Press, 1993), Flying over Tasmania (Fithian Press, 1997), Blue Damsels (Peter E. Randall Publisher, 2005), Night Call (Plain View Press, 2011), and, most recently, Dinner in the Garden (Columbia, South Carolina, 2018). A Gross Anachronism I am a physician, taking your pulse, pumping the ball for your blood pressure, warming my stethoscope before I listen to your heart, asking you to breathe deeply, hold your breath as I percuss your lungs. Now I am a doctor of screens, I visit you on zoom, you enter my waiting room, you are flat on the screen, your voice electronic, I dont know when you will stop talking. I dont know what you wear from the waist down, what shoes. I no longer touch you. Is this the oath of Maimonides that I took 50 years ago, this technology, a mere thread of the tapestry medicine, an anachronism of virus and social distancing? 151 Elizabeth Weir grew up in England and lives in Minnesota. Her book High on Table Mountain was published by North Star Press in 2016 and was nominated for the 2017 Midwest Poetry Book Award. She received four S.A.S.E./Jerome awards, and her recent work has appeared in Evening Street Review, Gyroscope, Turtle Island Quarterly, Talking Stick, and the Kerf On the Day the Pandemic Was Declared March 11, 2020 Beyond breakfast and my kitchen window, a Red-tailed Hawk landed, awkward, on the lawn. I watched it hesitate, spring upwards, legs extended to clutch at something unsuspecting in the grass. The hawk rose with a garter snake writhing in its talons, flew to a bare branch and tore at the head. The flailing lash of tail stilled as the hawk ripped and gulped down chunks of flesh. The snake had been basking in warm sun when death darted in. 152 Kari Wergeland, who hails from Davis, California, is a librarian and writer. Her work has appeared in many journals, including New Millennium Writings, Pembroke Magazine, and Chariton Review. Her chapbook, Breast Cancer: A Poem in Five Acts (Finishing Line Press, 2018), has been named an Eric Hoffer Book Award Finalist. Meanwhile, her long library career has taken her into libraries up and down the West Coast. At some point in all of this, she served as a childrens book reviewer for the Seattle Times. Pandemic Stave churches were built in Norway before Black Death opened its eyes and lumbered over cities, leaving the streets littered with dead. Long staves took a long time to cure. A father would start the process a son might finish, watch the church materialize, resemble a Viking ship with menacing dragons on each end to ward off evil spirits. They meant business. 1000 churches built in time to take on the plague but only a few edifices survive. These remaining vessels shift and creak with the rocking of time wooden engineering holding firm. Its an important voyage for those used to steel, 153 plastic stone even for people who have never experienced a pandemic until now. 154 Getaway On the road, first public restroom after 10 weeks of sitting in my own germs. Someone holds the door open gratitude I dont have to touch it. A bare hand shoves coffee out the drive-through window. Miles later, I observe few masks in the grocery store. Highway curving alongside the sea. I pull into the driveway, slip into my tiny shelter like a hermit crab with suitcases, laptop, groceries, books. I plan to buy a puzzle from the friend who sells gifts. Spray the knob before locking up rub it down. When I take my masked walk, I spot what followed me here dogging my attempts to soar, I bow to the horizon, go back inside wondering if this shell will take on the clams jaw. 155 Kat Bodrie is a professional editor and creative writer based in Winston-Salem, North Carolina. Her prose and poetry have appeared in Poetry South, Wild Roof Journal, West Texas Literary Review, Rats Ass Review, and elsewhere. Learn more at katbodrie.com. Uncertain Times To some degree life will be uncertain no matter what we do. Mick Scott how do you know you wont die tomorrow in sunshine, driving to the public library, Maui Jim sunglasses framing your oval face, burgundy skinny jeans youd hunted online hugging your ass and thighs its the perfect disguise an ugly moment posing with the right filter __ I take issue with uncertain we still walk & talk & fuck & make jewelry the measuring cup scoops out the right amount of Science Diet cat food twice a day how can I not create some amount of certainty for those I love __ this year, my twentieth high school reunion was cancelled ten years ago, I refused to go 156 and found out after none of my bullies were there maybe Ill never see my friends in person again maybe I dont need them __ they say chaos breeds creativity but this is normal fear events are the state of the planet we should start a newspaper and call it Uncertain Times __ in small print on page 1 section b some UN adviser says we are living in the shadow of nuclear war it is always a shadow bending over our shoulders reaching for the Times wouldnt it be ironic if one day it strangled us we never saw it coming __ in December, before the pandemic the bigwigs trimmed the fat: extraneous editors whose work would siphon to others. I sobbed in front of the HR lady who said I could take action if I felt it unfair: I thought I was there to turn in medical paperwork for a standup desk to help my IBS and reflux, back pain, poor circulation I packed a box with all my unseen illnesses and didnt look back 157 __ interviewer: what is it like living in todays uncertain times? the cat does not respond continues licking her belly like a furry seal on the verge of sluggish extinction 158 Ellen Sazzman has recently been published in A3 Review, PANK, Connecticut River Review, Ekphrastic Review, Paterson Literary Review, Womens Studies Quarterly, Sows Ear, Lilith, Beltway Quarterly, Southward, Dash, Miramar, Common Ground, and CALYX, among others. Sazzman received an honorable mention in the 2019 Allen Ginsberg poetry contest, was shortlisted for the 2018 ODonoghue Poetry Prize, and was awarded first place in Poeticas 2016 Anna Rosenberg poetry competition. Sazzman was also a 2012 Pushcart Prize nominee by Bloodroot Literary Magazine and a 2010 Split this Rock finalist. Her poetry collection, The Shomer (Finishing Line Press 2021), was a finalist for the Blue Lynx Prize, a semifinalist for the Elixir Press Antivenom Award, and a semifinalist for the Codhill Press Poetry Award. Sazzman is a writer living in Maryland, although Sazzman grew up in Cleveland, Ohio. Long Division in The Time of Quarantine Charlotte does not want to learn Long Division. Who can blame her the operations not childs play. Marshalling Digits, more Digits than She possesses. Digits separated For their own good into Columns, hundreds, tens, ones, Soldiers in lockstep, Obeying orders, carrying Down Carrying Down, always less and Less. Mother the MD is worried the Pandemic has become endemic. Self-Isolation, the solution, is not spontaneous, Cannot be calculated in the head or on fingers. Deployment requires a strategy, supply lines, Paper, pencil to notate the problem, an eraser For mistakes. Artillery. Grandma is enlisted 159 To zoom-teach. Grandma is practiced for better Or worse at apportioning Affection and paring Back. Charlotte hates all those D words and that lopsided bracket Missing a leg that shields Dividend from Divisor Until the siege when Divisor invades Dividend Repeatedly and takes away, takes away, Deriving, finally, the quotient whole number With/without a remainder, Leftover phantom, a sum Sometimes estimated into a nullity, A zeroing out some Denounce as Assault. Grandma imparts safety in numbers. Pairs split too easily. Pairs are the answer, chants Charlotte. Into Noahs ark The animals come marching two by two. She wants To press her mouth against her best friends ear, Whisper of the boy she has a crush on and the body That was hers ripening into anothers, secrets She no longer shares with her mother. The amputee bracket stands Upright under its weight of Correctness. 160 Kate Pashby (they/them) is a queer Mexican American poet from San Jose, California, who resides in Washington, DC. Their work has been published or is forthcoming in the Santa Fe Literary Review, Genre: Urban Arts House, Embryo Concepts Zine, Constellate Literary Journal, subTerrain Magazine, Northern Otter Press, The Confessionalist Zine, Burrow, Rogue Agent, and Rabid Oak. Kate was nominated for Best of the Net 2020. exit the immune system I once took great solace in the thought that if there were a coronavirus outbreak I could be among the first to die incapable also of surviving the first wave of a running zombie apocalypse without the medications that allow me to walk I wait for the infusion nurse to plug my arm into the IV find the thick vein that likes to roll back and forth, a cigarette between my deceased grandmothers thumb and forefinger I run my lotion-soft palms over cracked knuckles bleeding from cold air and hot water and yawn waiting for the tragic and untimely death 161 that was never promised to me, the one who could not come to terms with the possibility of a long, fulfilling life 162 Mike Wilsons work has appeared in magazines including Cagibi Literary Journal, Stoneboat, the Aurorean, and the Ocotillo Review, and in Mikes book Arranging Deck Chairs on the Titanic (Rabbit House Press, 2020), political poetry for a post-truth world. Mike resides in Central Kentucky and can be found at mikewilsonwriter.com. Until We Hug Again April 10, 2020 Today is Good Friday, social intercourse is a venereal disease and capitalism clicked on pause. I watch old movies where strangers are kissing and reckless crowds arent social distancing. After I drown the voice of Donald Trump in the bathtub of common sense I see something peeking behind the trunk of a fast-growing pine pungent in sap thats rising to the occasion. I fall to my knees believing Sunday movies will disappear and everyone will take their clothes off and hear trees preach the sermon of centuries from an astral plane. I raise my eye to the sky and chant a song the uncloudy day and everyone sings along. 163 John Grey is an Australian poet, US resident, recently published in Orbis, Dalhousie Review, and Connecticut River Review. Johns latest book, Leaves on Pages, is available through Amazon. Stuck At Home One Home is God. These walls, floor and ceilings are Americas soul. And God says, via his agents here on Earth, that I am at the precipice so stay back. For some virus has put together a war machine that could be from a lab or a bat, or that same God because, according to his televangelist disciples, he hates homosexuals. So if I have to be here, cocooned inside God, Id best start working on a Bible. The book of Covid-19. The book of Trump. The book of Pence. The book of Fox News. And how the new Ten Commandments was written on the brim of a MAGA hat. 164 Make America god-fearing again. Huddled in our homes, fear, fear and fear some more. If only I had a gun. Id line up that virus in a rifles sights and blast it right between the eyes. Thats how they did it when the country was young. During the Revolution. In the Civil War. My neighbor hung a noose from a beam in his garage. But he didnt go through with suicide. Hes not well but he doesnt want to die before he gets to eat at his favorite restaurant one more time. And who knows when that will happen. Two I envy the birds. They dont live long enough to die of something new. Even the rabbits they look at me as if 165 Im the worst thing that could happen. They dont realize that we giants have our own hawks and bobcats to be concerned about. They hide inside droplets in the air, can strike at any time. When youre invisible, size is no matter. Ive seen every movie twice. Ive read the same books over and over. My days are reruns. The true groundhog slips into nursing homes at night, condemns the inmates to an eternity of winter. The survivors will forever see his shadow. Some day it will all be over, so Im told. God will die, his dominions collapse, followers dissipate. I will walk out into the world and rediscover its magic. Yes, that means you, bookstores. No one will do a Lazarus on my banking account. 166 But other people will look less like the enemy. My mask can come off. The cloth one that is. All others will remain. (My parents, in heaven, are missing all this. Maybe they look down through some kind of telescope. Maybe theyre the voices I hear.) Three Somebodys on tv, declaring that theyve made a complete recovery, survived a trial by lung. Theyre now free to breathe in all those chemicals that will ultimately kill them. (No matter how I die, I anticipate a tremendous path, a billowing flow. the power that was the heart given over to the spirit. In the meantime, I could really use a week at the beach.) The phone rings. Its someone I havent seen in months. 167 How are you doing? asks the voice on the other end. Surviving, I reply. Even if I wasnt quarantined, I doubt I would have got together with them anyhow. And they would not have phoned. So the virus has a flag I can fly now that I am a country. A phone call. I open a window and it blows in the wind. 168 Gerard Sarnat won San Francisco Poetrys 2020 Contest, the Poetry in the Arts First Place Award plus the Dorfman Prize, and has been nominated for handfuls of 2021 and previous Pushcarts plus Best of the Net Awards. Gerry is widely published, including in Buddhist Poetry Review, Gargoyle, Main Street Rag, New Delta Review, Northampton Review, New Haven Poetry Institute, Texas Review, Vonnegut Journal, Brooklyn Review, San Francisco Magazine, Monterey Poetry Review, the Los Angeles Review, the New York Times, the London Reader, and Review Berlin as well as by Harvard, Stanford, Dartmouth, Penn, Chicago and Columbia Presses. He has authored the collections Homeless Chronicles (Pessoa Press, 2010), Disputes (Pessoa Press, 2012), 17s (Pessoa Press, 2014), and Melting the Ice King (Pessoa Press, 2016). Gerry is a physician who has built and staffed clinics for the marginalized as well as a Stanford University professor and healthcare CEO. Currently he is devoting energy/ resources to deal with climate justice, and he serves on the board of Climate Action Now. Gerry has been married since 1969, has three children plus six grandsons, and is looking forward to future granddaughters. gerardsarnat.com Intensive Care Unit Blues Though I have seen my head (grown slightly bald) brought in upon a platter, I am no prophet and heres no great matter -- T.S. Elliot, The Love Song of J. Alfred Prufrock i. Star Chamber Asterisked elder at-riskers* are now briskly dust/whisked off by their brusque feral caregivers themselves without bad vertebral disks which prevent us from being as frisky as in our distant past -- or at much real COVID peril although unlike balding me, they may need to go for haircuts. 169 * just speaking for Gerry ii. Patients Just Fading Away haiku Failed anonymous septuagenarians name image likeness. iii. I See You In ICUDo You See Me? -- thanks to Eliana V. Hempel M.D., Blood Ties, NEJM, 28May20 Distraught woman before us with that hunted look in her eyes seems all too familiar. Filigreed monogrammed hankies make repeated trips from mouth to lap then back again as our collective horror at the rapidly increasing amount of bright red froth intensifies. Shes barely able to breathe let alone talk rationally as metallic smells mingle with Moms viral raw fear. iv. C-Ward #17 -- thanks to Silvia Castelletti, M.D., A Shift on the Front Line, NEJM, 4JJune20 Thursday. Just finished another shift. Look me over in barber-shopoid cascading mirrors: C on nose from doubled-up N95 masks worn all the time and leaving deep marks engraved by four overlapping elastic bands. Eyes are tired. Hair damp with sweat. Oy. Im simply a physician no longer now also one unprepared soldier drafted to fight against invisible Coronavirus blown in dirty wind. Before frantic nightshift, I have to don protective gear whichs when get predictable adrenaline rush Earlier in on-call room with colleagues, 170 you try to crack bad jokes but our bodies must reflect shared worry regards shielding selves adequately as we attempt to carry out correct steps dressing: gloves, gown, second pair of gloves glasses, cap, mask, visor, shoes, shoe covers tape over tape to keep everything sealed. Persons who help you dress write name/ role on white lab coat with a red marker because thusly-costumed, no staff recognizes once familiar teammates. After s/he says Done, its showtime to face the music. Each caregiver feels like about to jump from humming plane, hoping their very-complicated parachutes will pretty-please open to keep us clean plus safe. Entering is walking into some surreal silent bubble with sounds muffled by mounds of heavy equipment. For first ten or fifteen minutes cant really visualize since breathing fogs my visor until it adapts to cooler ambient temperature. Then gradually begin to see between droplets of condensation, proceed into ward hoping shoe covers wont come off (as usual). Ninth shift so far this week starts. 171 David Estringel holds a Bachelors degree in English. His poetry and short fiction have appeared and/or are forthcoming in online and print publications, such as the Setu Bilingual Journal, Azahares Literary Magazine, Route 7 Review, the Blue Nib, Pif Magazine, Cutthroat: A Journal of the Arts, Latin Anthology, Rigorous Magazine, Bosphorus Review, Lahar Magazine, the Bitchin Kitsch, and Drunk Monkeys. David has also been a lead editor at The Good Men Project and editor at Red Fez and the Elixir Magazine. Digging for Lost Temples Thumbing through The Borderlands, I cant help but feel not brown enough. Im Mexican Lite. Got a case of the coconuts. There are no rageful battle cries inflaming this breast. No bitterness lingering on the tip of the tongue (the back of hands and the starch of white collars taste just the same no matter the bearers color). No tortured soul, longing for identity and re-appropriation. Theres just me and this suit of rosy-beige meat that touts my value best in the dead of winter. If youre not pissed, you arent paying attention, some people used to say. Others, Were nothing but second-class citizenswetbacksto them! (My back dried three generations ago) Then, there is all this talk of The Wall, as if one had actually never existed before in the first place. How funny people are when the invisible begin to reflect the Spectrum of Things in the cruel clarity of daylightancient atrocities shining, unforgivingly, like newly minted coins under brusque fluorescents. When did symbols become more real than the things they represented? (Maybe around the same time detention centers and concentration camps meant different things?) Better them than me, I would think to myself. Everyones got to hate someone, right? Call it apathy. Detachment. Indifference. Call it what you like, but dont let an absence of tears convey a treason of the flesh. I know where I come from and where my people have been. I am one of the many brown bodies that was piled in heaps, used as target practice by Texas Rangers that stood proudly before them, posing for photographs. I swung low from sturdy boughs in the Southwest, proving Strange Fruit plucked in all its hues and flavorstastes coppery and bitter in Lifes maw. I starved outside with the rest of the dogs, staring into diner windowsmind, body, and spirit consumedbarred from entry, wanting for crumbs. The narratives my own, but the story remains the same. Im no ones machisto, gangbanger, Latin lover, wetback, or Spic. I am no ones pimp, Sancho, caballero, or maricon. I cant roll my Rs, I hate tequila, and I dont code switch. Sheepskinspaid by my own coinadorn my walls, not holographic portraits of The Last Supper or La Santa Muerte adorned with plastic red roses from the dollar store. I am not spicy like something that is novelly consumed. And 172 Ia being, self-determined, not cast from a vulgar mold respect Gods will as much as he respects mine (which doesnt say much). The blood of peasants and slaves, warriors and kings run through our veins. Our ears once heard gods whispers through the rustling of leaves in the breeze and the trickling of streams over timesmoothed stones. We rode the winds--the sun kissing our backs (not breaking them)as we flew through fields of pale azure upon Serpents wings, over treetops and verdant expanses. We ate our enemies courage and drank victors wine with lips, stained red, from their skulls. (So, step back with your tallboys and that Four Lokos jive!) This is what lies beneath the skin. Melanin be damned! We are the sons and daughters of Earth and Sky, Aztec Temples of Sun and Moon, buried beneath blanched soil, crowned by cathedralspapal tiaras anointed by brown blood that pepper the land like so many gravestones. Remember? Remember! So, I pray to the Archangel Anzaldua to help me find my lost sovereigntymy words wafting up into the clouds on velvety ropes smoke of sandalwood incense and braided sweetgrass. Tears of honey fall from Heaven upon my skin, feeding cuts and scrapes no one (not even I) can see. Unfolding her rainbow-hued wings, like Hebe on Olympus, she descends with arms outstretched and an angelic smile. Face to face, she pulls me close, blesses my forehead with champurrado-scented kisses then tugs at my ear and says with the fire of cinnamon on her tongue, Huerco, just love the skin youre in! 173 Lisa Bullard has written ever since she could. She was raised in Montana where she was once bucked off a horse and didnt get back on. She now lives in the Pacific Northwest with her husband and two children. Before having children, she travelled around the globe on a shoestring, and since children she has found a new appreciation for packing snacks and a change of clothes for all excursions. Besides writing, she enjoys snowboarding, hiking, canoeing, and binge-watching shows while folding tiny items of clothing. She has taught writing courses at colleges and universities in Washington, Montana, and New York. Papa: The Awaited Guests Arrive and Other Poems Time I used to think of time as flowing forward relentlessly marching forward never to be snatched back or bargained back even with good deeds or repentance but in my own mind time travels backwards again and again to times I crave forgetting to people who hurt me even to times I feel deep in my DNA but cannot place on my tongue at night especially I fall backwards tumbling through time in the wrong direction back through history that is my own and is not behind closed eyes and closed doors bending the laws of time that were laid out that say time moves in one predetermined direction: forward 174 Youve Got to Have a Plan for when your burned-out flame finds you because he thinks the stars you wished on together the dreams you whispered to one another meant that you were meant for each other forever he thought the poems he wrote would be the only poems you would get from a lover you loved him youve got to know what to do if he shows up and thinks you owe him you once nurtured him the same way you nurtured a new kitten who lost his mother youve got to know how far you would go youve got to got to got to have a plan have a plan have a plan 175 A Flashback time clutches me with a sudden grip one second I wait for sleep and the very next: NO!!! but I cant stop the assault on my mind as he looms over me again and I am powerless again raped again terrified paralyzed I leave my body again and return again seconds pass trapped in the memory but the anger stays raging and the shame I want so bad to shake and I lay awake feeling betrayed by time and my mind 176 You, Papa Standing by the bank of the Birch Creek I stoop down and dip my hand into its icy current and the water moves past me I cant hold onto it I think of you, Papa, I struggle to grasp you but again you slip away and I knew you more in my mind than not, you always left away to Texas, away to Nevada, away to Alaska you look different from every angle and when you arrive you slip through my fingers again and the slap of my expectations sting and I try to please you, to be your girl and oh how you are proud of me but you forget birthday after birthday you miss most of my plays you arent there to screen my dates but you took me fishing and we laughed together and you baited my hook and gutted my fish and fried it on the fire for our dinner and I cling to that memory rolling it in my hand like a smooth stone but then you leave again and again youre always leaving then you drink too much again you come late to my wedding and you leave early and we dont dance a father/daughter dance but you give me a plaque you made when you were a little boy a homely looking plaque featuring a hand-painted hunting dog and I hang it, cherished, on my wall 177 I. Papa: The Awaited Guests Arrive doop-doop-dee-doo A little tune for you, dearest dear dear dear dear daughter . . . oh, okay, so Im a little just a little drunk . . . hee-hee-hee but just hang on, sit tight and CHECK THIS OUT! Wooo-eeee! Jeff gave me this harmonica tonight! See! We drank a little whiskey to celebrate YOU coming for a VISIT! Oh you know I miss you kids! doop-doop-dee-doo. Ha ha ha. And heres a little tune to you my son-in-law, son-in-law doop-doop-dee-doo Can you tell I just played harmonica For the first time in my life TONIGHT! Wooo-eeee! Am I glad youre here. I LOVE you two! You know that dont you? Woweee! I love you! doop-doop-dee-doo. Ha ha ha. 178 II. Daughter: Cotton Candy Land: Its Where Weve Always Lived the words are stones in my belly stuck in my throat sand in a pipe and damned if Im going to let them out now I feel like Im three years old again and I dont want to be! This brings back too many memories. I cant laugh because its not funny to me. I love you, Papa, but I cant be around you when youre drunk. Im leaving. we dont do that in our family we carefully look away we forget what we saw when we remember, we pretend that we dont its all cotton candy for us everything is okay for us sweet soft and fun for us if we can just stuff enough cotton candy in a volcano maybe it will turn into a candy land if we can just get it right and damned if we wont try and damned if we wont go crazy trying I tell myself to lighten up its just a fun time dammit I can laugh myself back to cotton candy land Ha Ha Ha! Thats so funny, Papa! Ha Ha Ha! Wow! What a frickin musical genius! Ha Ha Ha! 179 Connemara Wadsworths chapbook, The Possibility of Scorpions, about the years her family lived in Iraq in the early 1950s, won the White Eagle Coffee Store Press 2009 Chapbook Contest. Her poems are forthcoming or have appeared in Prairie Schooner, Solstice, San Pedro River Review, Smoky Blue Literary & Arts Magazine, and Valparaiso. The Women was nominated for publication in Pushcart Prize Best of the Small Presses by Bloodroot Magazine. Connemara and her husband live in Newton, Massachusetts. Mask Making I have oiled the machine, cut the cloth, the last of the lining. Im still mastering the technique of sewing in elastic, laying in pleats. How easy masks are to misplace. Each coat must pocket one, each purse, glove compartment. I will stitch some with color, and pattern to shelter in. Ill pleat one that will herald Lichtensteins red lipstick kiss. Another from a bandana appliqud with the corner triangle, another with sequins along the unremarkable edges. 180 Maybe take a Sharpie marker, write, Ten feet away please. It is the nature of its design to mask smiles, frowns leaving us to read only each others eyes. They say this wont be over soon. Ill tailor thin shieldsmake more masks from cloth scraps. 181 IV. BOOK REVIEWS 182 Jess Montgomery. The Stills. New York: Minotaur Books, 2021. Reviewed by Betty J. Bruther Jess Montgomerys new book in the Kinship Historical Mystery series takes a deep dive into Prohibition and its impact on the people of fictional Bronwyn County, Ohio. Returning as main characters in the book are Sheriff Lily Ross and her friend Marvena Whitcomb Sacovech, the protagonist of The Widows, which explored the world of coal mining in Appalachia through the eyes of two womenone, a member of the local elite, the wife and widow of the local sheriff Daniel Ross; the other, a widow, a member of the working class. The author highlights the efforts of union organizers to expose the unsafe conditions in the local mines and the tyranny of the mine owners in the company town through the medium of a murder mystery. A second novel, The Hollows, works in the same manner, allowing the author to explore two major themeswhite supremacy and male privilege. As the new story, The Stills, opens, a teenage boy witnesses a seemingly murderous attack on a federal agent. In the aftermath of the attack, he drinks some of the moonshine that he was guarding, and collapses. Sheriff Lily Ross is forced to arrest and imprison Marvena Sacovech, the producer of the illicit spirits, which are believed to be tainted. Subsequently, Sheriff Ross discovers Marvenas moonshine is not tainted; instead the teenagers sipping has revealed that he has sugar diabetes. Marvena had produced the moonshine to raise money to treat her daughters severe asthma, which is treated through her grandmothers homeopathic treatments and the local doctors prescription of 183 asthma cigarettes. As for the diabetes, the youngster learns to inject himself with insulin. Faith healing, folk medicine, and scientific remedies for common ills are a secondary focus of this text. Sheriff Lily Ross also discovers that two individuals from The Widows have returned to the countyElias and Luther Ross, both of whom had been involved in local corruption and the murder of her husband, Daniel Ross. Their appearance is the first of a series of events, including two murders that shake Sheriff Lily Rosss faith in her friends. George Vogel, a crime boss, and his minion, Abe Miller, are back, as are his new wife, a local, Fiona Weaver Vogel, who has inherited property from her recently deceased uncle, Henry. George Vogel has plans for isolated, rugged Bronwyn County he wants to build a secret moonshine factory on his wifes property. Furthermore, as readers discover, the federal government has poisoned manufactured alcohol, so that it cannot be used as a base in making illicit spirits. Rumors of tainted alcohol spread throughout the community, threatening the independent craft distillers. In fact, George Vogel plans on tainting the local speakeasys alcohol, but the plan is revealed. Both Luther Ross and Elias Ross are removed permanently from the tale; George Vogel goes to jail. Two murders are solved. A Christmas celebration ends the tale; life returns to normal in Bronwyn County, Ohio, in December 1927. Women are the stars of the seriesLily Ross, the sheriff; Marvena Sacovech, the workingclass country woman, and even the nascent crime lord, Fiona Vogel. Each woman proves strong and resilient. They chart their own courses, overcoming obstacles set in their way, leaving behind the societal expectations of their roles. For example, in The Widows, Lily and Marvena work together to solve the murder of the sheriff, Daniel Ross, whose widow, Lily, has been appointed sheriff to serve out his term until a special election. Often municipalities and counties did this very act, appointing the widow to serve out her deceased husbands term until an election, so that the family could receive a paycheck. Often the women were just figureheads, but in real life as in the novel, some became excellent law officers, winning election in their own right. Readers also take a deep dive into the life 184 of an Appalachian coal miner. The novel opens with the explosion and deaths of miners at the Widowmaker mine, located near Rossville, a classic company town. A local miner and union organizer, Tom Whitcomb (Marvenas brother) has been accused of Daniel Rosss murder. Lily and Marvena investigate the murder, one hoping to reveal the truth about her husbands death and the other, hoping to clear her brother. During the investigation, readers are introduced to life in the company town, where the mine owner, Luther Ross, pays the miners in company scrip, not U.S. currency, forcing them to purchase food and other necessary items from the company store. He also owns all housing in the town, so he can evict union organizers and others that he feels are a threat to his profits. He can even close the company-owned elementary school, so that the older boys are forced to work in the mines. George Vogel, the regional crime lord, has invested in the mines, hiring enforcers to help Luther Ross suppress the union organizers. Both men place monetary profit over human lives. Although the two women solve the murder, they find themselves making a Faustian deal for the greater good of the community. Rather than face arrest for conspiracy to commit murder, George Vogel withdraws his money from the mining company. Once that happens, the mining company is sold to new, more humane owners. The new owners allow the establishment of a union and upgrade mine safety. Tom Whitcomb is cleared of any complicity in Daniel Rosss murder, but the men who ordered the sheriffs death are allowed to leave the county. Approximately six months later in The Hollows, Lily Ross, the newly elected sheriff, becomes embroiled in another murder, the brutal death of an elderly woman thrown in front of train. The elderly woman holds a dark secret which is revealed over the course of the novel. Lily Ross and Marvena Whitcomb discover the pernicious role of white supremacy and male privilege in their community. Lily finds that her community has a white supremacist underbellythe presence of a womens chapter of the Ku Klux Klan. The elderly woman, suffering from what is clearly Alzheimers disease, called dementia, has retreated into her distant past, escaping from the local mental asylum, 185 The Hollows, and wandered into danger. Her secret, written in her journal, rests hidden in the asylum. Meanwhile, Hildy Cooper, a friend of the women, finds herself rebelling against the expectations of her mother, who has arranged for her marriage to an older wealthy man. Cooper inserts herself into the investigation, placing herself in some danger as a resident of the asylum, so she can find the womans journals. She reads the journals, finding a mentor in the life of a world traveler and adventurer. She finds the courage to break her engagement. The journals also contain an explosive secret, a member of the regional elite has been passing for white unknowingly. As a child, the elderly woman had carried a newborn African American child to an abolitionist family where he was raised as a white man. Since that time, members of the family had left behind their abolitionist beliefs, embracing the Ku Klux Klan and white supremacy. The killer hoped to maintain the family position in society, and therefore, brutally murdered the old woman. As for the novels, they fit neatly into the regional historical mystery genre, allowing the reader to explore the history of a particular time and place, touching on current hot button issues, such as feminism, socialism, and racism, all within the context of a re-created world. You, as reader, can be looking over the shoulder of a private investigator, Alba Flavia, walking the mean streets of Imperial Rome in the first century of the Common Era or the eye of the red tsar, Pekkala, walking across Red Square in Stalins Moscow searching for the truth about the deaths of the Romanovs. And you might learn a bit of history. Betty J. Bruther is a retired instructor of history at Marian University in Indianapolis. 186 Where We Stand, written by Donnetta Lavinia Grays, directed by Dwandra Nickole Lampkin, Summit Theatre Performance, May 22, 2021. Reviewed by Ben Tebbe On a warm evening in May, on the campus of Marian University in Indianapolis, a lone actor hummed her way from the grassy audience area to the nearly empty stage of the Allen Whitehill Clowes Amphitheatre. On her way, she subtly encouraged the diverse gathering of 50 or so souls to join her in rhythmic clapping to keep time as her hum transformed into a song reminiscent of a spiritual. She was inviting us along. Our act of clapping together in unison creating a community. And the story she was ready to tell was all about community. Where We Stand is a new play by Donnetta Lavinia Grays and from May 21 to 23, 2021, was presented as a staged reading by Summit Performance Indianapolis. The play weaves poetry, song, and theatre together in a unique experience. A solo performer, named simply Man, attends to us as an everyman or perhaps a better description would be as a griot in the great tradition of African storytellers. As Man begins, he is pleading for forgivenesspleading for his very lifegrateful that we are holding our stones until his story can be told. What unfolds is moving and relatable. A story of someone on the outside who wants in. Of someone who is bombarded with messages to make his life better. Out of the blue he is presented with a bargain from a golden stranger with a quick fix to turn him and his town from a used to be into a still could be. But it all will come at a cost. Man, in this staged reading is played with full, powerful delivery by Manon Voice. Though Ms. Voice is not a traditional actor, she is a talented artist, poet, and spoken-word performer. Throughout 187 the story she embodies several other townspeople. And while her physical performance vocabulary may have been a bit limited, her robust vocal instrument facilitated clear definition of each new character being introduced. As a staged reading, Voice kept her script with her, but she displayed complete command of the tale belying the fact that she and director Dwandra Nickole Lampkin rehearsed only a week. The ease and comfort with which they fostered community throughout the play was manifest. Where We Stand, though in many ways a straightforward narrative about a downtrodden Man being swayed to a quick fix, is profound because of its medium. Theatre has always created community when an audience joins performers in a space to share a story. But in this case, we as audience are also forced to become the community of the story. In the end, we must decide the fate of Man. Choose forgiveness or accountability. Compassion or punishment. One of the striking things about this piece is that the playwright has insisted the performer be Black. As a white man, I felt the weight of passing judgement on this character. Additionally, it occurred to me that we as the community in the story were complicit in the towns downfall. For me, all blame could not be placed on Man. On this particular Saturday evening, the majority of our community chose forgiveness. And Man was grateful. At times, it feels a bit like Grays is trying to fit too many big themes in her piece and the ending is rather abrupt following the vote. But overall, the rhythm she creates with the piece is captivating. The play calls up notes of religion and freedom and mercy. And she captures the truth of humanity that what we all want is community, friendship. And maybe even more so after a year of pandemic life and protests demanding equity for Black bodies. Gratitude, mercy, and compassion certainly go a long way to cultivate community. Summit Performance, in a lovely touch, enlisted Danicia Mont Malone to moderate a post-show discussion which was a beautiful extension of our community experience rounding out a beautiful late-spring evening. As a professional, women-focused theatre company Summit has produced several 188 staged readings over its few-year history with more planned in the future. Through this outlet they can present newer plays or harder-to-fully-produce plays. But they have the formula down, and with Summit one can expect enough stage and minimal reading for a full experience. An experience with a community. Ben Tebbe is an assistant professor and director of the Marian University, Indianapolis, theatre program. 189 Gannis, Scott. Very Fine People. Dayton, Ohio: Atlatl Press, 2020. Reviewed by Doug Sheldon Scott Ganniss freshman outing, Very Fine People, takes its title from Donald J. Trumps reference to white supremacists during the violence at Charlottesville, Virginia, in 2017. It introduces us to Jude Glick, a midwestern adult-orphan, working part time as both a comedian and a museum security guard and inching toward probable suicide. A former child frenemy, Stephen Scheisskopf, has wandered back into his life as the campaign associate of a Trumpian figure running for president. Schiesskopf exploits Glicks life story (poverty, addiction, sickness, premature death, crippling debt) to mold a far-right narrative drawing supporters to his candidate. Glicks self-loathing then escalates and soon progresses outward and imposes itself on the far-right supporters with catastrophic aptitude. Very Fine People is more of a choleric essay cosplaying as a novel. It paves a road made from anger at the 2016 election but does not quite weave itself into solid fiction. The narrator, Jude, swirls like many did in the 20162020 haze of fascist resurgence and drags readers along with him while cloaked in a veneer of hard-boiled retorts posing as narration. But that might be the hidden fun of Ganniss debut: that so many people I know, including myself, identify with Judes anger early in the thinly fictionalized Trumpian universe, until his inward thoughts trickle outward to force him on-thelamb. For example, Jude breaks narrative saying things like A few thousand people, active oppressors, or active oppressor adjacentmeditation appropriators, and the speciously thoughtful flannel wearers who want to bone them (8) and while funny and observant, it doesnt add much to the books 190 attempted message of anti-fascism. Jude appears more whiney than righteous. This might be Gannis point, to show murky nature of current political identity, yet Judes narration often cannot meet this goal. Much of the narrative paragraphs read like Twitter threads, rant-ish, distracting, and, intentional or not, come off disjointed after a few chapters. When it comes to executing cohesion in a long-form narrative, Very Fine People falls a bit flat as the fury-layered pages lose steam building toward acts of violence consequential to Glicks journey. Although, one thing is clear: Gannis did his homework. Borrowing the simmering despair of writers such as Dashiell Hammett, Dan Chaon, and, most obviously, Joseph Heller, we get a narrator you cannot stop listening to. No matter how much the narrator drips with rage, some of it justified and some of it privileged, you root for him, even if you dont want to, as he attempts to delegitimize the dark forces swirling in pre-pandemic America. There are great twists and interesting characters that pilot Glick around in this ill-fated pilgrimage. Gannis exudes great rhetorical accuracy when assessing the copied-and-pasted speech of extremist actors, which stems from Schiesskopfs strategizing, and illustrates the antidemocratic nature of populism. There are even moments where Glick questions his own growing extremism after justifying the fame of a domestic terrorist like the Unabomber: The fuck is wrong with me? With us?... could I ever forgive myself regardless (p. 193). There is a sense of roundness to Glick. He is not just a flat extremist turned domestic terrorist or a cartoon drooling at death, but a complicated middle-American torn between extremism and decency who feels abandoned by his country and thirsts for revenge. The novel concludes with a confessional authors note in which Gannis searches for sympathy in a senseless world. This feels like the whole novel distilled into four pages. He jabs lovingly at readers, reminding us all of the way we might have felt in late 2016, that we are connected by tissue and bone to those dark four years that followed. But the connectivity of this mini-revelation does not translate 191 into the text of the novel itself. In the end, Very Fine People falls into a similar trap in which many contemporary novels of the Trump era have found themselves: sacrificing story for message. This could be avoided, perhaps, if the self-loathing comedy of the novel took time for introspection rather than extrapolation. The sojourn for a great line, a pithy quip, or a darkly comedic paragraph has won out over narrative in Very Fine People, but damn if this anti-Goldfinch isnt a compelling examination of how fantasy-heroics can char the edges of a movement. Doug Sheldon is a writer, scholar, and professor living in the Midwest. His work has appeared in Flyover Country Review, Midwestern Miscellany, Mid-America, and Teaching Hemingway and Gender. 192 Susan Abulhawa. Against the Loveless World: A Novel. New York: Simon and Schuster, Inc., 2020. Reviewed by Fouad Mami. Against the Loveless World is Susan Abulhawas third novel. Her Mornings in Jenin (2010) and The Blue Between Sky and Water (2015) are accelerators toward this work. Here, Abulhawa spells the ABCs of the Palestinian revolution to come. Readers do not encounter the terror-stricken Yousef of the first novel, nor the damaged Nur of the second. One cannot get enough of Nahr (river in Arabic) if only because she is a voluptuous dancer. Nahr is not a secondary character as with Epic of Gilgamesh. Instead, Nahr stays le racteur conceptual of the revolution, but she does not attribute any narcissist role to herself. As there exists no script to follow, it is her being that metamorphizes to the essence and that, in turn, organically develops to a concept for the revolution. Nahr embodies in absolute certainty the way a revolution becomes irreversible. Only when the would-be revolutionary dances erotically does life become incendiary. Readers meet Nahr when she is incarcerated in the cubicle, a high-tech security facility that targets the detainees knowledge of the absolute. She narrates her exile from its beginning in the pre1990 Kuwait City, when a large Palestinian community is building Kuwait. Nahr marries Mhammed with presumably unmatched credentials as a revolutionary, which explains why he is a celebrity among Palestinian girls in the city. Because he is gay, Mhammed cannot reconcile with his strict gender expectations and painfully leaves Nahr. As her familys main source of financial support, Nahr takes various odd jobs until she meets Um Buraq in a wedding ceremony. An Iraqi living in Kuwait, Um 193 Buraq is enchanted with Nahrs dancing and adds her to a team of girls in an underground brothel for rich khalidji customers. The night Saddam Hussein invades Kuwait, Nahr and two other girls are entertaining exacting Saudi emirs who turn out to be extremely abusive. With the occupation underway, the emirs are arrested and later executed, showcasing poetic justice. With the liberation of Kuwait, Palestinians become overnight personae non gratae in a country that they helped build from the sands. Nahrs family find themselves refugees in Amman now. Under the Oslo Accords of 1993, Nahr is finally convinced to visit the West Bank, terminates her divorce papers, and remarries. Mhammeds brother, Bilal, facilitates the daunting procedures and Nahr slowly becomes entangled in Bilals secret workflow. She discovers that under a surface of docility, underground groups from multiple villages form autonomous resistance cells to Israeli occupation. After earning their trust, Nahr becomes part of Bilals unit and helps organize several painful blows. In consequence, she must serve an eighteen-years prison sentence. This explains why readers encounter Nahar in the cubicle early in the novel. Exchanged in a deal, readers meet her in closing in Amman. She sees Bilal again but resists the urge to publicly reunite as he is still on the Israelis wanted list. The novels world is far richer than the details of its plot. If Karl Marxs call for communist revolution, his disposition against the state and money, or his historicist approach seem too abstract, Nahrs choices facilitate the reception of such abstractions better than the finest professor in the finest institution. Nahr embodies Marxs Gattungwesen, the life of men and women free from alienation. She incarnates the ontological vibration of the primordial tradition predominant before the Neolithic Revolution. Readers discover that the communism of the future can be no other than the way Nahr, Bilal, Samar, Jumana, and Ghassan live, with or without occupation. Before resorting to the armed struggle, they are mentally clear that the revolution is how they need to challenge their societys sedimented gender roles and sanctions of morality. Their anti-statist logic does not waver before either 194 Israel, Palestinian Authority, Jordan, or Kuwait. Any state, they find, is the codification of alienation. During the short window of time between the Iraqi occupation and American liberation (August 1990January 1991), Nahr witnesses first-hand how money is commodity fetishism. With inflation escalating like wildfire, people reclaim communism almost in a reboot mode. Even when not articulated as communism, that brief experience undid the ghettoization into Kuwaitis, Iraqis, and Palestinians. The proof for an underlying revolutionary approach is that Nahr did not have to shy away from her past as a sex worker. Still, not shying away is in no way championing that past. Rather, it is despite that past, perfectly understandable with the logic of undesirable refugees in the Gulf, that she was able to reflect on her conditiona reflection that tolerates the emergence of a radical consciousness actively seeking to reverse the collective misfortune. Her radical logos results from bypassing private misery, refusing to sabotage or coerce ones clarity by zooming in instead on the collective injustice. Sex work is redefined to signify not subscribing ones life force in the reversal of occupation, any occupation. Nahr forces comparisons with both Zoulikha in Assia Djebars La femme sans spulture (1976) and Hajj Khaled in Ibrahim Nasrallahs Time of White Horses (2007). Hatred for opponents fails to motivate these three protagonists. Unsurprisingly, they lack personal enemies. With these three characters, readers note the ancestral breath of the hunter-gatherer. As Nahr admires the curve shaping her breast (reveling in her Dasein), readers cannot overlook the parallel of the curve with the hunters arch. Both subscribe to the same sacral (not sacred) breath. In hitting the prey, the hunter seeks sustenance, not profit. Readers close the novel with the conviction that whoever cannot dance cannot qualify as a revolutionary. Fouad Mami is a professor of English at the University of Adrar in Algeria. 195 Clint Jones. Stranger, Creature, Thing, Other: Monstruous Reflections on Our Ecostential Crisis. Stevens Point, Wisconsin: Cornerstone Press, 2019. Reviewed by John William Nelson You and I are monsters. So too is Clint Jones, and in his book, born out of a lecture series on the Environmental Humanities, he makes it clear that all of us had better get in touch with our own monstrosity before it is too late. Part jeremiad, part pop-culture reference work, this book offers a philosophical compilation of Joness environmentally conscious musings about humanitys future in an age of inevitable global climate shift. Taking the monster as an avenue through which to discuss humanitys relationship to a dying world, Jones proposes it is time to upscale our own knowledge of the self to keep pace with the upscaling of our social understandings (p. 3). In other words, as we grow increasingly aware of the scale of a global calamity that threatens the entire earth, and accept our devastating role in that crisis, we must rethink our own positionality within nature and embrace our strangeness as a monstrous species apart. Jones approaches the question of our place within global climate shift from the perspective of philosophy. In Joness interpretation, philosophers dedicated most of the twentieth century to the questions of existentialism. This existential preoccupation was a reaction to a series of human-induced wars and catastrophes in the twentieth century, but Jones proposes we move beyond such queries to a new mode of thinking that he terms ecostentialism. In this new ecostentialism, we move beyond asking questions of being to questions of our belonging within the natural world. The trope of the 196 monster offers an accessible way into these questions for even those without a philosophical background. In Joness chapters, various monsters from lore and pop culture offer valuable lessons for humans within a failing world. For instance, vampires, werewolves, and zombies serve as destructive consumers of one stripe or another. Humans have fallen prey to their consumer appetites, in the process ruining not just their own prospects but the environment around them. To amend these disastrous habits, we must begin to think as creatures with a relationality to the world beyond us. As Jones puts it, we need to shift from an anthropocentric relationship to creation bolstered primarily by hubris, luster, and a stubborn unwillingness to see ourselves enmeshed in the world to something more collaborative, and more sustainable (p. 79). Jones effectively weaves his themes of the monster with useful critiques and accessible distillations of a range of thinkers. His thoughts on Karl Marx are worth noting, as he shows that the ghostly inheritance of Marxist critiques, while useful against capitalism, are not capacious enough to correct all that is wrong with our world amid global climate shift. But for all of Joness calls for global thinking and capaciousness, a few elements of the book read as oddly provincial. Rather than outlining the threats of climate change in global terms, for instance, Jones discusses such threats in the language of Americentric regions: Northeast, Midwest, Southwest, etc. Such a limited scope reads jarringly when matched with the bulk of Joness arguments, but hints at a larger tension in the workthe balance between localism and universalism. Writing from the intellectual ecosystem of WisconsinStevens Point, this book is a product of both a local academic community and a manifestation of our global concerns as survivors in the Anthropocene. This observation is less a critique of Joness work, however, and more a reflection on the larger challenge that continues to face us as intellectuals within the humanities: how to expand our interpretations to answer a climate dilemma of global proportions while staying grounded and accessible to our 197 geographic and academic locales. Joness use of the monstrous offers us one medium through which to brave such a daunting task. His take serves as a suggestive, if not definitive, interpretation of how we might think of ourselves as both a species apart while also intimately responsible for the survival of our wider world. John William Nelson is an assistant professor of history at Texas Tech University, where he teaches courses on early American, environmental, and Indigenous history. 198 James H. Madison, The Ku Klux Klan in the Heartland. Bloomington: Indiana University Press, 2020. Reviewed by John Lepley History clashed with memory when USA Today interviewed Adam Driver about his role in the 2018 film BlacKkKlansmen. Raised in Mishawaka, Indiana, Driver recalled the Ku Klux Klan as a ubiquitous presence throughout his childhood. If anything, I was more aware of it as a kid growing up in Indiana because they were always Klan rallies, like, every summer, he shared. However, James H. Madison, a historian at Indiana University, threw cold water on this reminiscence. Most of the memories of this sort tend to be grossly exaggerated, but at the same time, its quite possible that he [Driver], saw men and women in robes and sheets. Its quite possible that he saw a burning cross. But not a lot of it, Madison explained. 155 We ought to cut Driver some slack, though; his recollection exemplifies the history that Madison describes in The Ku Klux Klan in the Heartland. In the early 1920s, the Indiana KKK boasted over 300,000 members, peaking in 1922 1923. Madison contends that too much attention has been focused on its elites, particularly Grand Dragon D. C. Stephenson. Instead, he tells us to look at the rank and file that organized Klaverns in every county in the state. In the American heartland, the Klan found its best people, Madison writes. (p. 2). Nativism, 100% patriotism, and militant Protestantism provided a milieu that African Star Wars Actor Adam Driver Says He Had KKK Neighbors in Indiana, 5Chicago, modified Aug. 21, 2018, https://www.nbcchicago.com/news/local/star-wars-actor-adam-driver-says-he-hadkkk-neighbors-in-indiana/49645/ 155 199 Americans, Jews, and Catholics threatened to tear asunder. While the Klan reinforced de jure and de facto structures to marginalize African Americans, they were never considered as dangerous as Catholics (p. 95). The Klan is usually associated with virulent racism because of its origins in the aftermath of the Civil War and resurgence during the Civil Rights era in the 1950s and 1960s. However, the Great War intensified the suspicion with which white Protestants regarded the Eastern and Southern Europeans who immigrated to the United States in the late 1800s and early 1900s. By the 1920s, these factors created a siege mentality upon which the Klan erected a formidable redoubt. The Ku Klux Klan in the Heartland is outstanding regional history. The endnotes reveal deep archival research. One-third of the monograph is visual; two galleries feature photographs and images illustrating the Klans pursuits. A flyer for a Klan picnic in Vincennes advertised One Whole Day of Diversified Delight and Amusement; several photos bear the name of W. A. Swift, a Muncie photographer who covered Klan functions. Still, Madisons focus on the local level unearths a deep vein of exclusion and division in the American past writ large. Running through that history is racial, ethnic, and religious conflict and hatred, he continues (p. 7). Hoosier Klan members were not illiterate backcountry rubes who eschewed civic and patriotic ideals. To the contrary, in their minds, they were its defenders and evangelists who used modern technologies to promulgate their creed, enforce moral standards, and regulate who belonged to the nation. Less than a decade after Woodrow Wilson screened Birth of a Nation at the White House, the Klan produced the films The Toll of Justice and The Traitor Within that portrayed the Klan as a nonviolent moral reform organization (p. 107). Madisons emphasis on the Klans cultural, political, and social aspects creates a rich history, but it lacks a political-economy perspective that would have enhanced his argument. For example, did the postwar glut in agricultural commodities influence Klan membership? The distinction that Madison makes between the Klans intimidation of African Americans and the violence the Klan actually perpetrated invites scrutiny as well. Even if there are no primary sources to support the claim 200 of an intensely violent Indiana Klan, (p. 110) mere threats are on the same spectrum as actual deeds. Chapters on the Klans critics and opponents, its political endeavors, the downfall of D. C. Stephenson, and brief revivals in the latter decades of the 20th century round out this excellent contribution to midwestern history. Drivers recollections of the Klan prompted others to speak up. Corey Havens, a reporter for the South Bend Tribune, documented several instances of Klan violence and hate group activities in Indiana in the 1990s and early 2000s. Travis Childs, an educator at South Bends History Museum, who had also cast doubt on Drivers claims, owned up to his mistake. I was shocked. I would never have guessed there were that many events. Shocked and saddened, he admitted. 156 In an ironic way, this row anticipated Madisons conclusions in The Ku Klux Klan in the Heartland. The Klan story does not give comfort. It rests at the core of American history, not at the margins (p. 198). John Lepley is a labor educator in Pittsburgh, Pennsylvania, and graduate of Indiana State Universitys MA program in labor and reform movement history. Yes, There Were Plenty of KKK Rallies when Adam Driver Lived in St. Joseph County, South Bend (IN) Tribune, Aug. 21, 2018, https://www.southbendtribune.com/news/local/yes-there-wereplenty-of-kkk-rallies-when-adam-driver/article_ddeafc15-d21f-5cce-beff-6e48f66a1e00.html. 156 201 Nicholas Newman, The Political Works of Remigius Dei Girolami. Belleville, IL: St. Dominics Media, 2018. Reviewed by Samuel C. C. Bunch It is certainly no secret that we citizens of the United States are a people fiercely divided into political factions. It is no more a secret that many of the controversies of our day are bound up in questions regarding the proper relationship between the moral precepts of religion and the laws of the states. Considered in this light, it is easy to understand why Nicholas Newmans study and translation of several of the works of Remigius Dei Girolami might be seen as a timely and relevant contribution to both historical scholarship and public intellectual discourse. Newman provides, in the opening pages, a concise and effective introduction to the Investiture Crisis, explaining how the question of whether the supreme temporal authority (in the form of the Holy Roman Emperor) or the supreme spiritual authority (in the form of the Roman Catholic Pope) is greater than the other in earthly affairs had produced an extremely volatile political situation. Newman places readers in the context of a city of Florence riven by violence and controversy, which is itself a part of the larger Italian peninsula that has also been riven by violence between its various states, and throughout the book reiterates this historical context as necessary to understanding the works of Dei Girolami, who was both a citizen of Florence who sought the common good of the citys people and a Dominican friar loyal to the Catholic Church and the Roman Pontiff. Newmans central claim appears to be that Dei Girolamis purposehealing the political divisions and their destructive consequences for the city of Florencewhich the friar would have 202 witnessed firsthand during the late 1200s and early 1300s, is advanced by utilizing a philosophical framework which emphasizes the common good and repeatedly calling attention to the damage to the polity caused by the neglect of the common good, particularly the goods of peace and justice. The relationship between Dei Girolamis works on the common good, peace, and justice is brought to the fore by Newman when he addresses the scholarly debate over which of the works preceded and influenced the others. He takes the position that Dei Girolamis work on the common good was written first, and his case for that position is well argued. Perhaps more interestingly to lay readers, his introductions help in understanding how Dei Girolami viewed peace and justice in light of the common good. One of the lines from Newmans translation of Dei Girolamis sermons on the topic of peace is an excellent example of the rich material Newman is drawing upon: injustice does not permit peace to be kept. Current-day activists who chant, No justice, no peace! would probably be surprised to learn that a Dominican friar writing in the 1300s had already argued that justice is a prerequisite for peace. It is also worth noting that Dei Girolamis lengthy arguments, many based on classical philosophy and reasoning by analogy from nature and demonstrating that the common good is more important than certain individual goods, could well appeal just as strongly to secular critics of capitalism and consumerism as they do to Catholic integralists. Fortunately, this brief volume is written in a style accessible to scholars and to educated layfolk. Scholars of history and political science who cannot read Latin may greatly appreciate the new English translation of Dei Girolamis works and Newmans citation-heavy introductions to those works. The book-loving political activists seeking to contextualize current controversies will find much food for thought on the relationship among the common good, the church, and the states. Catholics trying to find a way to reason clearly about the common good and peace and justice as a response to 203 contemporary crises might discover that they are both challenged and reassured by Dei Girolamis own efforts to accomplish the same. Samuel C. C. Bunch is currently working to enter the novitiate with the Eastern Province of the Order of Preachers and reading the works of Dominican authors past and present. 204 Thomas Sanfilip. Conversations with Mona Lisa. Des Plaines, IL: Bigio Marato, 2019. Reviewed by Jennifer J. Smith Reading Thomas Sanfilips Conversations with Mona Lisa is a bit like looking at a Marc Chagall painting: the pieces are dreamlike, often ethereal, yet tethered to everyday reality. Sanfilips volume of prose poems and poetry paint images and scenes that blur around the edges. The book is divided into untitled, numbered sections, and the prose poems within each section contain recurring images or settings. One section focuses on a hospital room where the speakers sister is close to death, while another section evokes a day spent at the seaside. Sanfilip wishes to capture poetic consciousness as the speaker moves through and bumps into the world. More than a few pieces are dedicated to surreal dream sequences where the speaker seems to have found human connection only to awake and have missed it. These fragmented poems capture consciousness at those moments when it pauses before rushing on to the next image; in doing so, the book attempts to mirror the human psyche in its wanderings. An early piece invokes the eponymous Mona Lisa as muse. Sanfilip begins by establishing the setting: The crowd pushes forward, the rapid fire of cameras clicking, flashes of light bouncing off the Plexiglas that shields the Mona Lisa from every conceivable assault of hot breathyet under fire she remains poised and gazes out with all her enigmatic wiles intact, tranquil, calm, patient and eternal. The speakers often resemble Leonardo da Vincis subject: aloof and ever present. They seem to be looking at the world through thick glass. He ends this same piece by directly addressing the woman at the center of the painting: Help me find my way to your side where I can speak without 205 fear and listening become one beyond the murder of your light, beyond the weight of your bones. Give me your last smile as the day wanes and the sky bursts in a flash of dying blue (p. 9). For me, the most compelling pieces were those tethered to a grounded reality. In a prosaic vignette, the speaker visits a library giving away books that have not circulated in twenty years, and the speaker finds a worn out biography of Cezanne, implying that it was once well loved and now obsolete. He next stumbles upon a book called The Pleasures of Antiquity, which prompts the speaker to laugh at the irony of old books left rotting (p. 52). In one of the pieces set at the seashore, Sanfilip captures what it feels like to be at the beach, writing, There are moments the air drops into absolute silence. The waves meekly run to shore without any noise. Even the drone of a small airplane is muffled a stillness, coming and going as though something muting the energies (p. 81). His language here mirrors the sense of suspension that comes with sitting where water meets land. The sense of suspension is also present in a powerful piece on a life-altering diagnosis of the speakers sister. Here he uses em-dashes to show the way that time contracts and elongates at moments where the body waits to see what will become of it: doctor questioning herpressing her swollen abdomenwe study her chest x-ray from the backenlarged heart I mistake for the left lung (p. 100). In this piece, as in the one on the Mona Lisa, the speaker approaches enigmatic images and tries to discern meaning. In many ways, all the pieces echo the questions that arise when he looks at Da Vincis masterpiece and the x-ray. What is real? What can be counted upon? What slips away? These are the central questions of Sanfilips volume. Jennifer J. Smith is an associate professor and chair of English at North Central College in Naperville, Illinois. 206  ...

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... Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 https://doi.org/10.24869/psyd.2021.475 0HGLFLQVNDQDNODGD- Zagreb, Croatia Review GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Najla Taslim1, Arthur D. Canales2 & Shrooq Mohamed T. Alshehab1 1 Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia 2 Department of Theology & Philosophy, Marian University, Indianapolis, USA received: 31.1.2021; revised: 23.3.2021; accepted: 30.3.2021 SUMMARY Gender dysphoria (GD)DFRQIOLFWEHWZHHQRQHVVHOI-perceived gender identity and the biological sex has been a wholly enigma and a source of contention between experts of various disciplines since long. This is a narrative review of the medical literature utilizing PubMed, Scopus, and Web of science databases, on the social status of GD patients, their therapeutic options, as well as the medical and ethical debate on GD that are of especial interest to the Muslim readers. Gender dysphoric patients or transgender people have a long history of social discrimination, marginalization, abuse, and neglect all around the world. Currently, large scale social developments supporting of transgender rights are rapidly underway in the west. Clinical evidence-based guidelines have also been published and are available for the management of GD, albeit with some medical and ethical concerns. On the other hand, the transgender community is continued to suffer profoundly in the developing and majority of Muslim nations, due to generalized unawareness, neglect, cultural and religious boundaries on this issue. Currently, Muslim youth or young adults are showing passionate interest in GD and are actively seeking information to comprehend its complexities, but they face more dilemma on this matter than the people in the West. This article addresses and discusses key transgender issues and controversies and provides a logical explanation that demonstrates that GD is real medical condition needing attention and that its treatment guidelines are justified. We hope this article will stimulate a new and broader perspective in minds of young Muslims and will urge them to take pragmatic steps in alleviating the travails of long-suffering and neglected transgender community. Key words: gender dysphoria transgender - Muslim countries - Islamic countries - Muslims * * * * * INTRODUCTION Gender dysphoria (GD) (previously known as gender identity disorder) is defined as an extremely distressful psychological condition evolving from a SHUVRQV SHUFHSWLRQ WKDW WKH\ DUH WUDSSHG LQ D ZURQJ body and belong to the opposite sex (American Psychiatric Association 2013). For instance, a male with GD strongly believes or feels that he is a woman and similarly with a female experiencing GD. The intense emotional pain associated with GD may be severe enough to cause funFWLRQDOLPSDLUPHQWLQSHRSOHVOLYes. Gender dysphoria patients are commonly referred to as transgender (American Psychiatric Association 2016). Recently, GD awareness is growing; Western countries are opening up to transgender people and talking about the issues that transgender folk experience. Sociopolitical reforms favoring transgender rights are rapidly taking place in the West and medical assistance is freely accessible to those opting to transform their bodies in line with their gender expression (National Gay and Lesbian Task Force 2008, Reisner et al. 2015a). Undoubtedly, major changes are observable in the West, but a breakthrough acceptance or awareness is still far away. Similar to the situation elsewhere in the world, GD has been contested and is a culturally sensitive topic in Muslim societies (Ishak & Haneef 2014, Saeed et al. 2018). Awareness about GD varies dramatically among Muslim countries with some showing legal acceptance; some rejection and others simply choose to remain oblivious to the existence and needs of transgender folks (Polat 2005, Wong 2012, Saeed et al. 2018) Retrospectively, a vast majority of Muslim countries have had shunned transgender discussion and mention of transgender people altogether as evidenced by a stark lack of research output and media coverage of any sort on this matter. Recently, younger generation of Muslim youth or young adults are showing keen interest in understanding and learning about GD, but simultaneously, they are confounded by diametrically opposing religious and sociocultural transgender views within Islamic denominations (Ishak & Haneef 2014). Therefore, understanding the complexities of GD is far more challenging for young Muslims than the people in the West (Saeed et al. 2018). No wonder, that many Muslims are still dubious and question the legitimacy of GD. This article provides a synopsis of transgender people or GD patients their reality, social and medical status followed by major medical and ethical views and controversies on GD, to the Muslim readers. Moreover, the article will discuss and analyze some key points that are of special interest to the younger generation of 475 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 Muslims based upon our observation and experience in Islamic societies. 7KH WHP \RXQJ RU \RXQJ SHRSOH will be used throughout this essay to refer to people who are 16-30 years of age. on transgender with GD and any mention of transgender would imply those with GD. THE REALITY OF GENDER DYSPHORIA (GD) METHODS A non-systematic literature review was conducted through PubMed, Web of science and Scopus databases to search English language articles that covered topics relevant to our objectives i.e. GD definition, related terminologies, medical management, social and health status of transgender community, medical and ethical controversies on GD. All selected articles were published between the periods of 1960 to 2020. DEFINITIONS AND SOME TERMINOLOGIES Oftentimes people use the words sex and gender indiscriminately in some cultures, like Middle Eastern or Indian subcontinent, without paying attention to the connotation or the implications thereof. Therefore, it is important to define these two terms for the readers of this article. Nature has created humans, principally, as males and females, but based on their behavior or gender expression, humans are also categorized as men and women. In most societies, males are defined as men and females as women - the so-called binary system of human existence (Wong 2012). However, in reality and rarely, this idyllic social model is disrupted when a puzzling scenario appears and a male passes himself as a woman and vice versa. Such people are termed as non-binary, gender nonconforming, gender atypical, gender variant or colloquially transgender or trans (Richards et al. 2016, Hyde et al. 2019). Many different variants of transgender people exist to date based on their behavioral profile as shown in Table 1 (American Psychiatric Association 2013). Notably, not all variants of transgender people suffer from GD as explained later under etiology (Levine 2018). Transgender folks who experience GD are greatly uncomfortable or agonized about the conflict between their gender and natal sex and seek sex change therapy (Joseph et al. 2017). This article is focused exclusively People with uncharacteristic gender behavior, lifestyle or mannerism, have existed in human societies since inception and are mentioned in the Scriptures [The Holy Bible: Isaiah 56: 45 & John 7:24; The Holy Quran: 4: 119] (Zurada et al. 2018, The Holy Bible 1989, The Holy Quran). In many Muslim cultures, there is not much awareness about the diversity of sexual and gender configuration, and the intersex, transgender, and homosexual individuals, are all viewed as the same thing, which is not the case (Jami 2005). Homosexual males or females are sexually attracted to members of their own sex but their gender identity is fully congruent with their sex. In contrast, most transgender people are heterosexuals because their sexual orientation is driven by their gender and not the biological sex (Nieder et al. 2011, Fein et al. 2018). Intersex people, on the other hand, have abnormalities of sexual development, and have ambiguous chromosomal or genitalia (Mouriquand et al. 2016). Etiology of GD Gender dysphoria has been an enigma as regards its etiology. Whether transgender behavior is an inherent feature or an acquired one, it is still being investigated. Numerous theories have been proposed to link its origin to genetic, hormonal, neurobiology, psychological or environmental factors (Berglund et al. 2008). The most convincing hypothesis is that alterations in prenatal hormonal exposure to developing fetus might induce some neuronal differentiation, which is responsible for GD (Mouriquand et al. 2016, Swaab 2017). Scientists also believe that environmental factors, such as family, lifestyle, cultural, and social values might also predispose a person to become transgender (Marantz & Coates 1991). However, none of the above theories have been proven on concrete grounds and further research is ongoing, to date. It is worthwhile noting that sometimes people adopt conflicting identity, temporarily or permanently for entertainment or commercial reasons and such people typically suffer no dysphoria about living or posing as the other gender (Levine 2018). Table 1. Definitions of some common gender variants Gender Expression Definition Gender queer or gender fluid Whose gender identity is unstable Bi-gender Those who experience two different gender identities Transvestites Those who cross-dress for psychological satisfaction, but the term is not really a term used anymore. Transsexuals Those who are or have already been through sex change therapy, commonly known as gender confirming surgery. Cis-gender Whose sex and gender are in harmony by social standards or their interior disposition is congruent with their exterior demeanor, like majority of the human population. 476 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 Global Status of Transgender People Below is a glimpse of the way transgender people are faring on a global stage, in two categories: socioeconomic status and health status. Socio-economic status A thorough and comprehensive academic review of the literature points to a bitter reality that transgender people are profusely abused, maltreated, disrespected, stigmatized, overtly or covertly, virtually in all societies (Grant et al. 2010, United Nations 2011, Bostwick et al. 2014). Data show that about 90% of transgender people are harassed and 25% have experienced physical assault because of their gender expression (Kosciw et al. 2012). Discrimination to transgender is exhibited everywhere whether it is an educational institution, healthcare center, employment sector or a place of worship (Kosciw et al. 2012, Bostwick et al. 2014). Professor Canales, succinctly describes transgender folks as the most maligned, misunderstood, and marginalized group in one of his numerous articles (Canales 2018a,b). Currently, Western societies are recognizing and are steadily becoming more tolerant of transgender issues by implementing trans friendly civil and legal policies, passing non-discrimination laws to provide protections for transgender people in employment, education, and healthcare (Transgender Law and Policy Institute 2012). Health status and statistics Numerous reports have also demonstrated that the transgender population is at 2-3 times higher risk of psychiatric illnesses such as anxiety, depression, social phobia and adjustment disorders compared to their cisgender peers secondary to the host of internal and external stressors shown in Figure 1 (*ymez-Gil et al. 2010, Reisner et al. 2015b). As direct result of experiencing marginalization, transgender people also have a high prevalence of substance abuse and suicidal behavior with 41% has actually attempted suicide in their lifetimes (Grant et al. 2010). It is also been reported that HIV risk is much higher in transgender population compare to the general population (Wilson et al. 2009). Transgender people in Muslim countries The state of affairs for transgender people in Islamic socities is not any different from the rest of the world, and perhaps it is far worse in some developing Muslim countries. Our literature review discovered that social and economic states of transgender people are deplorable in Malaysia, Indonesia, Pakistan and are marked by poverty, marginalization, abundant stigmatization, hatred, violence, neglect, lack of education, healthcare, employment opportunities etc. (Gibson et al. 2016, Saeed et al. 2018, Shah et al. 2018). High prevalence of human immunodeficiency virus and other sexual transmitted diseases among local transgender people in these developing nations is a major public health issue that have raised international concern (Akhtar et al. 2012, Wong 2012, Gibson et al. 2016, Barmania & Aljunid 2017, Vijay et al. 2018, Mitchell et al. 2019, Akhtar et al. 2020, Robbins et al. 2020). Unfortunately, most data on transgender people has been reported by a few Muslim countries, i.e. Turkey, Iran, Malaysia, Indonesia, Pakistan, and Nigeria. Figure 1. A depiction of the conglomerate of stressors for gender dysphoric patients 477 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 There is minimal or no representation of transgender people from Arab nations or the rest of the Muslim countries indicating a generalized negligence or lack of attention on transgender matters in these countries. To date, only three Islamic countries, Turkey, Iran, and Egypt legally recognize GD as a medical condition and offer medical management or sex change therapies to those seeking ways to align their bodies with their psychological feelings to adMXVWWRVRFLHW\VVWDQGDUGV Turan et al. 2015, Mazen 2017, Valashany et al. 2018). Pakistan has also recently granted its transgender citizens the rights of their gender expression regardless of their natal sex (Shah et al. 2018). Legally, the transgender community does have legitimate rights and a functional support system in Turkey, Iran and Pakistan. Nevertheless, the burden of social stigma and discrimination for transgender people is still a reality and is felt at all levels in these countries (Polat 2005, Saeidzadeh 2016). VARIOUS VIEWS ON GD AND ITS MANAGEMENT Understanding the root causes of the controversy regarding GD is paramount. The debate in medical and ethical disciplines that GD has provoked is extensive. The religious debate on GD is a substantial area and is beyond the scope of this article. Readers are briefly reminded that like Christian and Jews scholars, Islamic religious leaders also hold both conservative and liberal views on GD and its management (Ishak & Haneef 2014). Except for Egypt, Turkey and Iran, the rest of the Islamic states have prohibited sex change treatment to cure GD. Medical views and controversies Initially, GD was considered a psychiatric condition (Bancroft & Marks 1968, Green & Money 1969). However, after years of research, experts in the field are now convinced that GD is neither a mental or psychiatric illness nor a personal choice; rather it is an inherent conIOLFW EHWZHHQ RQHV JHQGHU DQG VH[ WKDW ZDUUDQWV intervention (Reisner et al. 2015b). Retrospectively, all other modalities including behavioral and psychotherapy approaches DWWHPSWLQJ WR FRQIRUP SDWLHQWV feeling of self-SHUFHSWLRQWRDOLJQWRDSHUVRQVnatal sex have proven unsuccessful (Bancroft & Marks 1968, Green & Money 1969). Evidence based management guidelines World Professional Association for Transgender Health [W3$7+@ KDYH HVWDEOLVKHG and published evidence-based treatment guidelines for GD (Coleman et al. 2012). According to these guidelines, the management of GD is aimed at alleviating the dysphoria or distress associated with the feelings of gender incongruence UDWKHU WKDQ DWWHPSWLQJ WR FRQIRUP SDWLHQWV IHHOLQJ RI self-perception to align WRDSHUVRQVQDWDOVH[(Coleman et al. 2012). Therefore, at present, the gender confirmation or affirmation or sex reassignment therapies (SRT), seem to be the only authentic option in relieving GD (Meyerowitz 2009). Table 2 presents diagnostic criteria for GD in adults and children (Zucker et al. 2016). It is apparent from a glance at the stepwise sequence of the treatment process shown in Figure 2 that SRT are quite an elaborate process. Given the extensive nature of the SRT, clinicians must ensure that the patient understands the protocols, and the short-term and long-term benefits, difficulties, and consequences of SRT. On the other hand, prescribers are also cautioned that after diagnosis of GD is established, any barriers or restrictions to SRT can culminate in devastating consequence for patients (Gridley et al. 2016, Wright et al. 2018). Initiation of SRT require meticulous evaluation by at least two health care professionals specializing in sex/gender issues to confirm the diagnosis of GD. After initial evaluation, GD patients are started on hormones treatment. Subsequent to adequate hormone therapy, which normally lasts 1-2 years, patients can proceed for surgeries. Before the surgeries, patient is asked to provide an evidence of social adaptability to a new gender role by dressing and living like a member of the desired sex. After passing all above criteria, only then the patients are deemed fit for surgical procedures (Coleman et al. 2012). Sex change surgeries are complex, multi-step procedures with a range of major and minor procedures that mandate postsurgical follow-ups and medical care for life (Table 3) (Coleman et al. 2012). Table 2. Diagnostic criteria for gender dysphoric children and adolescents or adults Children Adolescents/Adults Common diagnostic features Presence of a marked conflLFW EHWZHHQ RQHV JHQGHU DQG WKH DVsigned sex at birth combined with significant distress and functional impairment for at least 6 months. Age specific features The strong urges (desires), x Insistence on being the other sex x Showing strong predilection for choices x To be treated as the person of the other sex in clothing, toys, and playmates similar to the opposite sex children x A strong desire for the primary and/or secondary sex characteristics of the other sex x 7RJHWULGRIRQHVVH[XDOIHDWXUHV 478 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 Figure 2. World Professional Association for Transgender Health [WPATH] recommended stepwise approach for GD management Table 3. A few examples of common transgender surgeries Surgical Procedures Male to Female Major x Penectomy x Orchiectomy x Vaginoplasty x Clitoroplasty x Vulvoplasty Cosmetics x Liposuction/Lipo filling x Voice surgery x Thyroid cartilage reduction x Gluteal augmentation x Hair reconstruction The WPATH has set a very well-defined and standardized criterion for the diagnosis and treatment of SRT. The aim is to ensure that only transgender patients with intensely painful psychological feelings arising from the sex and gender mismatch are offered SRT. Simultaneously, it is also desired that GD patients should not be denied their right of changing their sex to normalize their lives. Medical concerns with sex reassignment therapies Successful SRT are, undoubtedly, commendable scientific DFKLHYHPHQWV LQ UHVWRULQJ D SHUVRQV JHQGHU Female to Male x x x x x x x x x x x Mastectomy Hysterectomy/Oophorectomy Vaginectomy Metoidioplasty Phalloplasty Scrotoplasty Erection and/or testicular prostheses Liposuction/Lipo filling Voice surgery Thyroid cartilage enhancement Pec-toral implants Forehead or check augmentation Rhinoplasty, chin and jaw recontouring dysphoric feeling; they are not without risk and caveats. It is wise to briefly discuss some points of concerns associated with SRT. Hormonal therapies are reversible and seemingly serve to reinstate the psychological well-being of children, youth and young adults (Corley et al. 1981, Hembree et al. 2017). However, the side effects of hormone therapies, albeit manageable require close monitoring. Current safety data on the hormone agents has mixed findings, though studies showing benefits outnumber the studies showing harm or serious side effects (Viner 479 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 et al. 2005, Weinand & Safer 2015, Hembree et al. 2017). Similarly, the outcomes of sex change surgeries are highly questionable with some studies showing improYHPHQW LQ SDWLHQWV TXDOLW\ RI OLIH DQG OLIH VDWLVfaction and others demonstrating high mortality rates, dissatisfaction, substance abuse, and poor quality of life with physical, and role limitations even 12-15 years after surgeries (Kuhn et al. 2009, Mur et al. 2010, Wierckx et al. 2011, Simonsen et al. 2016, Zeluf et al. 2016, Simbar et al. 2018, Fallahtafti et al. 2019). However, the surgical outcome depends on the nature of the procedure involved and the general health status of the patient (Djordjevic et al. 2019, Schardein et al. 2019). Unfortunately, until now we lack reliable, welldesigned, long-term studies with statistically significant data. Most of the studies in this arena suffer from methodological limitations, lack of right matching control, or small sample size inadequacies, which render conclusion less reliable (Levine 2018). All things considered, further investigation is required to gain clarity on the durable outcomes of SRT. Ethical views and limitations The complexity of GD does not culminate merely in scientific domains but extends to the ethics surrounding its management as well (Levine 2018). Followings are some points of ethical concern: Optimum time to start therapy The first ethical impasse to manage GD is to determine the right time to initiate therapy in children or adolescents. Not only the childreQV DXWRnomy is questionable at immature age; it is inconclusive if children are able to fully comprehend the repercussions of the medical and surgical interventions to give their informed consent (Bizic et al. 2018). On the other hand, delaying the treatment is highly likely to intensify the dysphoria related depression, anxiety, suicidal ideation, and subject the trans person to embarrassment, harassment, and feeling of incompleteness (Giordano 2008). Post-surgery regrets There are reports and incidents of people experiencing postsurgical regrets. The major risk factors are named as wrong GD diagnosis, poor psychiatric evaluation, unsatisfactory aesthetical or functional outcome of the newly created sex organs, lack of family support and feelings of guilt due to religious affiliations (Djordjevic et al. 2016). Unlike the hormone therapy, surgery is irreversible and this fact heightened the sensitivity of surgical interventions. Infertility is a concern for patients A highly emotional ethical predicament for transgender young people is to choose between their sex transition and retaining their reproduction ability. Not only cross-hormone therapy temporarily impedes the 480 infertility, surgical hysterectomy or orchiectomy can permanently deprive trans youth of the potential to bear their own off springs (Bizic et al. 2018). Since a vast majority of transgender adults aspire to have children, WPATH guidelines mandate that patients be fully and thoroughly informed of this major consequence of the SRT. Fortunately, some alternative options such as cryopreservation of the oocytes, sperms, or gonadal tissues are available that transgender can count on to procreate after SRT (Bizic et al. 2018, Ellis et al. 2015). Briefly, opting for the surgery is a significant ethical dilemma for the GD patients, their families and as well as the surgeons. DISCUSSION OF A RATIONAL APPROACH TO GD CONTROVERSIES In this section, we will discuss and try to logically explain the perplexing questions that linger in the minds of many in the Eastern and Middle Eastern culture. Is GD real? Since scientists do not know with exact certitude the causes of GD, it is difficult to pinpoint its origins. Well, after seeing so many worldwide cases, it is difficult to deny the legitimacy of GD. The etiology of many other diseases such as multiple sclerosis, fibromyalgia pain, Alzheimer disease, cancer, and the primary hypertension is also unknown. Therefore, it should not be difficult for XV WR DFNQRZOHGJH DQRWKHU P\VWHU\ FRQGLWLRQ OLNH GD. The overall global prevalence of GD patients is unknown due to underreporting and possible shame associated with the condition in Islamic culture (Shumer 2016). Still, data obtained from Western countries demonstrate that a significant number of people selfidentify themselves to be transgender people, for instance, 0.6 -1.4% in USA; 0.4 % in UK and 0.030.08% in Netherland, respectively (Van et. al. 1996, Conron et al. 2012, Ellis et al. 2015). Among Muslim countries, Iran and Turkey have published sizable number of articles on GD. With all of that information, it is hard to deny the legitimacy of GD. People might disagree whether GD is a physical, mental, or psychological issue, but it a real and legitimate medical perplexity. What is the right treatment for GD? Seemingly, most of the controversy, dilemma, and ethical concerns about GD revolve around its proper therapy; liberal-minded people corroborate the scientific facts and approve the evidence-based therapy for GD, while conservatives voice against SRT principally on religious or ethical grounds. Essentially, there are only two possible treatment options: (1) change the mind [psychotherapy] or (2) change the sex [hormone and surgical treatments]. Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 Is psychotherapy the right approach? Perhaps, conservatives would suggest that counseling and psychotherapy based conversion therapies are more appropriate for GD patient [to align their feelings to their natal sex]. As previously mentioned, studies have proven the futility of all such therapies including behavioral, spiritual, religious, and electro-convulsant techniques or the use of psychiatric medicines. Cultures that promote coercion policy to suppress any atypical thoughts result in seeing GD patients who suppress and conceal their gender expression and suffer internally (Reisner et al. 2015a). This does not seem to be a viable solution of ethical care or patient care within the medical community. Interestingly, some studies do suggest that 10-20% of children exhibiting GD like symptoms grow out of it during their adolescent or adult years (Hembree 2011). However, it would be wise to remember that our knowledge of GD is still evolving and much is still unknown. It is possible that those percentages of children were misdiagnosed and were transiently influenced by environmental factors. Is sex reassignment therapy the right approach? Sex reassignment therapies are exactly the medical procedure that a person struggling with GD desires; science supports such treatment and religious progressives agree. If SRT can be accomplished uneventfully, it will be an ideal scenario. But given the complications, regrets and guilt with the therapy, there is certainly a need to develop better, safer scientific techniques for SRT. It is wise to keep in mind that the two major causes of regrets after surgery or before surgery are the guilt of disobeying God and familial rejection, and not the SRT per se (Safavifar 2016). Both of these factors are only related to our hardline attitude toward SRT. Reports also indicate that the process of SRT, however, can by facilitated by the family support and care, not to mention the empathy, compassion, understanding, kindness, and love of the whole community that can make the entire process much more endurable (Polat 2005, Fallahtafti et al. 2019). Hopefully, the more reliable SRT procedures will be invented in the future. Good news is that the stem cells are on our door steps and scientists have already formed autologous organs in laboratories (Iannaccone et al. 2018, Becherucci et al. 2018). It is only a matter of time when organs can be regenerated and implanted to humans (Atala 2013). We should be hopeful that humans can achieve this. REFLECTION This point is a moment of reflection for all to ponder. Above, illustrates the way transgender people have been and are still being treated in the world. Abuse, violence, injustice, discrimination, neglect, rejection, deprivation are all part of transgender lives only because of their atypical appearance. It is only now that the medical science has provided transgender people the opportunity to amend their misaligned bodies to live normal lives and blend in a society. Unfortunately, in many Muslim societies transgender folks are ignored altogether; their existence is known, but no steps are taken to normalize them in society or alleviate their plight. Transgender people deserved to be given the choice to make decisions about their lives. It is time that we reconsider our behavior toward trans people, and change our minds on the ways we can accept them and assist them in their journey to treatment. FUTURE DIRECTION Two vital factors contribute to pitiful conditions for transgender people in the Muslim world: generalized unawareness and myopic religious views. Both factors demand a high caliber, multi-faceted, research on the transgender issues in Muslim countries. Scientific studies and theological research to highlight the root causes of transgender or GD, identify the merits or demerits of SRT, and to address the physical or psychological needs of the transgender people should be a research priority for Muslim countries. Collaborative research and dialogue will raise public understanding of transgender conditions, and will set the foundation for social reforms in Muslim countries to grant transgender people their human rights. CONCLUSION Gender dysphoria has always been a puzzling and controversial phenomenon worldwide. In most Muslim countries, GD has been considered a far more complex and culturally sensitive subject as compared to the West. The discussion of GD treatment in these Muslim countries has been ignored since long. Consequently, in the trans community there is suffering on many counts, in silence, for years without any platform to voice their physical and psychological needs. Recently, Muslim young people seem to be interested in broaching upon transgender related topics. Through this article, we offer young people a glimpse into GD along with the global status of those living it, and the current medical and ethical dilemma surrounding it. We hope this discussion is logical, and our Muslim readers will be able to glean that GD is a real medical issue and deserves treatment. Whether the medical procedures are complicated, reliable, right or wrong, under the circumstances, we would be wise to let the trans person decide for themselves and be supportive to them either way. Raising more public DZDUHQHVVLQLWLDWLQJDFWLYHUHVHDUFKDQGFKDQJLQJRXU mLQGVUDWKHUWKan that of GD patients, can bring forth a swift, happy, and peaceful solution to this suffering minority population. 481 Najla Taslim, Arthur D. Canales & Shrooq Mohamed T. Alshehab: GENDER DYSPHORIA: A MEDICAL AND ETHICAL PERPLEXITY AS DISTINCT FROM REALITY AND THE RATIONAL APPROACH FOR MUSLIM YOUNG PEOPLE Psychiatria Danubina, 2021; Vol. 33, No. 4, pp 475-484 Acknowledgements: Authors highly acknowledge the contribution and assistance of Ms. Amal Turikham Alghamdi for helping the literature search and short listing relevant articles from Muslim countries and Ms. Akira Jbeen for editing this manuscript, preparing references and providing technical assistance. Conflict of interest: None to declare. Contribution of individual authors: Najla Taslim conceptualized, designed and drafted this article. Arthur D. Canales provided mentorship supervision for the writing and conceptualization of this article besides editing and revising the document. Shrooq Mohamed T. Alshehab provided insightful ideas, helped in literature search and articles selection. References 1. 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