tag:theconversation.com,2011:/id/topics/selected-stories-31251/articlesSelected stories – The Conversation2019-09-26T18:22:53Ztag:theconversation.com,2011:article/1243212019-09-26T18:22:53Z2019-09-26T18:22:53ZWould ousting Trump rebuild the country’s faith in government? Lessons from Latin America<figure><img src="https://images.theconversation.com/files/294391/original/file-20190926-51438-78ag0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reporters ask Nancy Pelosi about the formal impeachment inquiry against Trump.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Trump-Intelligence-Whistleblower/61c57ac3d4164ebfb32beb42e192331e/56/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>The House of Representatives has <a href="https://www.washingtonpost.com/politics/2019/09/25/what-you-need-know-about-impeachment-inquiry-into-trump/">opened an impeachment inquiry</a> against President Donald Trump. But what happens if a president is impeached?</p>
<p>The vice president would take his place, but other parts of the government continue unchanged. Partisan polarization can be magnified in the process. Many Americans already think the government is <a href="http://www.people-press.org/2017/04/17/3-views-of-congress/">too divided along partisan lines</a> and that <a href="http://www.rasmussenreports.com/public_content/politics/general_politics/june_2017/for_sale_congress">corruption</a> has reached <a href="https://www.washingtonpost.com/local/dc-politics/dc-and-maryland-to-sue-president-trump-alleging-breach-of-constitutional-oath/2017/06/11/0059e1f0-4f19-11e7-91eb-9611861a988f_story.html">the highest levels of government</a>. These beliefs fuel <a href="http://www.npr.org/2015/11/23/457063796/poll-only-1-in-5-americans-say-they-trust-the-government">declines in public trust</a> and <a href="http://www.gallup.com/poll/208526/adults-name-government-dissatisfaction-important-problem.aspx">dissatisfaction</a> with the government in general.</p>
<p>In my book on the <a href="https://www.cambridge.org/core/books/achilles-heel-of-democracy/729655118E5C21315EA768CE19291434">rule of law in Central America</a>, I discuss several occasions in which presidents were removed from office before their terms ended. </p>
<p>The current political crisis in the United States shares similarities with political issues in Latin America. We are seeing <a href="http://www.people-press.org/2016/06/22/partisanship-and-political-animosity-in-2016/">radical partisanship</a>, <a href="http://www.pewresearch.org/data-trend/political-attitudes/congressional-favorability/">public dissatisfaction</a> and <a href="http://www.rasmussenreports.com/public_content/politics/mood_of_america/right_direction_wrong_track_jun26">perceived poor government performance</a>. Since only one U.S. president has left office due to wrongdoing, examples from Latin America can give us some perspective. </p>
<p>Lasting <a href="https://www.brookings.edu/blog/brookings-now/2015/05/06/40-years-ago-church-committee-investigated-americans-spying-on-americans/">reforms after Watergate</a> came from a <a href="https://www.senate.gov/artandhistory/history/common/investigations/ChurchCommittee.htm">congressional committee’s investigation</a> and recommendations, rather than from the simple resignation of President Nixon. Impeachment is <a href="https://theconversation.com/impeachment-its-political-77528">inherently political</a> and, as I have observed in Latin America, does more to punish enemies than clean up politics. Removing a president who is a “bad apple” may help, but a real cleansing takes more effort.</p>
<h2>After impeachment</h2>
<p>Take Brazil as a case in point.</p>
<p>Former President Dilma Rousseff <a href="https://www.theguardian.com/world/2016/aug/31/dilma-rousseff-impeached-president-brazilian-senate-michel-temer">was impeached</a> in 2016 in the midst of an anti-corruption investigation known as “Operation Car Wash.” There were already pending corruption investigations against <a href="http://www.latimes.com/world/mexico-americas/la-fg-brazil-impeach-20160328-story.html">37 of 65 members of the congressional impeachment commission</a>, but none of them were forced from office. It is no surprise that Rousseff’s impeachment appeared to many to be <a href="https://www.theguardian.com/global-development/2016/jul/05/in-brazil-women-are-fighting-against-the-sexist-impeachment-of-dilma-rousseff">inspired by sexism</a> rather than just anti-corruption efforts.</p>
<p>Rousseff’s replacement, President Michel Temer, <a href="https://www.reuters.com/article/us-brazil-corruption-idUSKBN19J2R5">was charged with</a> corruption-related offenses in June 2017. However, Temer’s political party and their allies controlled the majority of the Congress and the president of the Congress was an ally of Temer’s. A formal impeachment never went forward, but Temer <a href="https://www.bbc.com/news/world-latin-america-47658080">was arrested in March 2019</a> after leaving office.</p>
<p>We see a similar failure to pull out the root of corruption in the “Guatemalan Spring” of September 2015. Then Guatemalan President Otto Pérez Molina was forced to resign in the face of massive popular protests. He was implicated in an investigation into corruption at the national customs agency, for which he was arrested the day after his resignation. He had also been accused of <a href="http://www.bbc.com/news/world-latin-america-36060524">taking bribes from a Spanish firm</a> in exchange for granting it a lucrative long-term contract with the government of Guatemala.</p>
<p>An election was held just four days after Pérez Molina’s resignation. Jimmy Morales, a television comedian with no political experience, won the presidency over a former first lady. Morales ran as an outsider with the slogan “not corrupt, not a thief.” After his first year in office, <a href="http://www.telesurtv.net/english/news/Guatemalan-President-Jimmy-Morales-Marks-Inefficient-1st-Year-20170112-0017.html">which opponents have derided as “inefficient,”</a> Morales <a href="http://www.reuters.com/article/us-guatemala-corruption-idUSKBN16E2PW">faced a corruption scandal</a> involving accusations that his son and brother had fraudulent dealings with a government agency.</p>
<p>Take an older example, from Honduras. The <a href="http://harvardpolitics.com/united-states/us-honduran-coup/">military coup against Honduran President Manuel Zelaya in 2009</a> was authorized by that country’s Supreme Court and was backed by <a href="http://www.nytimes.com/2009/06/29/world/americas/29honduras.html">the majority of its Congress</a>. The Honduran Supreme Court argued that Zelaya was planning to reform the constitution to give himself more power as Venezuelan President Hugo Chavez had done. </p>
<p>Some eight years after Zelaya was removed, Honduran political elites continue to <a href="http://www.insightcrime.org/news-analysis/corruption-honduras-result-of-functioning-system-report">participate in widespread corruption</a>, including <a href="http://www.insightcrime.org/investigations/honduras-elites-and-organized-crime-introduction">direct ties between some political elites and organized crime</a>. Because so many of the elites are corrupt, none of them <a href="http://carnegieendowment.org/2017/05/30/when-corruption-is-operating-system-case-of-honduras-pub-69999">rock the boat.</a> </p>
<p>Even prosecuting and jailing presidents for corruption doesn’t seem to solve the problems that lead up to these crises. Often the rest of government continues to be overly partisan and even corrupt – and public satisfaction with government drops even lower. </p>
<p>In <a href="http://news.bbc.co.uk/2/hi/americas/3299289.stm">Nicaragua</a> and <a href="http://www.nytimes.com/2011/04/28/world/americas/28fbriefs-EXPRESIDENTF_BRF.html">Costa Rica</a>, for example, former presidents have been jailed on corruption charges, but those convictions were <a href="http://www.nytimes.com/2009/11/16/world/americas/16nicaragua.html">ultimately</a> <a href="http://www.ticotimes.net/2015/12/05/appeal-court-acquitts-ex-costa-rica-president-miguel-angel-rodriguez">overturned</a> on appeal. In 2013, Guatemala became the <a href="http://www.cnn.com/2013/05/10/world/americas/guatemala-genocide-trial/index.html">first country</a> to convict a former head of state of genocide in a national court. Ten days later, the Guatemalan Constitutional Court <a href="http://www.bbc.com/news/world-latin-america-22605022">reversed</a> General Efraín Rios Montt’s conviction over an evidentiary matter – and Rios Montt then <a href="https://www.theguardian.com/world/2018/apr/01/ex-guatemalan-dictator-efrain-rios-montt-dies-aged-91">died in 2018</a> before a <a href="https://www.ijmonitor.org/2017/04/rios-montt-to-face-second-genocide-trial-for-the-dos-erres-massacre/">new trial</a> could occur. The point is, it is extraordinarily difficult to make charges stick against even a former president, especially if he or she still has sizable support in the government.</p>
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<img alt="" src="https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294392/original/file-20190926-51401-12r53ut.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Molina spoke at a conference as president of Guatemala in 2013.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/SOP-AP-SPANI-SPAN-XUN-SPANUNJD120-GUATEMALA-ENT-/b291e2cfd6894c868678c0922edb4c35/3/0">AP Photo/Jason DeCrow</a></span>
</figcaption>
</figure>
<h2>Beyond impeachment</h2>
<p>Problems with governance are rarely fixed by going after even an unpopular or corrupt president if fundamental institutional problems are allowed to continue unchecked. Impeachment’s weakness is compounded by its often partisan deployment. </p>
<p>What else can be done to clean up politics? </p>
<p>The hard work of demanding <a href="https://www.foreignaffairs.com/articles/brazil/2017-04-13/brazil-s-never-ending-corruption-crisis">transparency</a> more generally may help get at the root of the problem. Guatemala’s experience with an <a href="https://www.insightcrime.org/news/analysis/5-takeaways-cicig-guatemala-anti-corruption-experiment/">international anti-corruption commission</a> helped local officials shine a light on official wrongdoing at every level of government. However, that commission’s <a href="https://www.dw.com/en/guatemalas-un-anti-corruption-body-a-victim-of-its-own-success/a-50277624">mandate expired on September 2, 2019</a>, following <a href="https://theconversation.com/guatemala-in-crisis-after-president-bans-corruption-investigation-into-his-government-109864">clashes with the president</a> over an investigation into his own actions.</p>
<p>Ultimately, using <a href="https://www.foreignaffairs.com/articles/brazil/2017-06-02/brazils-best-shot-against-corruption">legal channels to improve political institutions</a>, rather than focusing on just one bad politician, can enhance the rule of law. </p>
<p><em>This is an updated version of <a href="https://theconversation.com/would-impeaching-trump-restore-the-rule-of-law-lessons-from-latin-america-80127">an article</a> originally published on July 11, 2017.</em></p><img src="https://counter.theconversation.com/content/124321/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel E. Bowen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the House mounts an impeachment investigation of President Trump, examples from Central and South America show that ousting an executive leader from office doesn’t always have the intended effect.Rachel E. Bowen, Associate Professor of Political Science, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/754342017-07-16T18:09:27Z2017-07-16T18:09:27ZWhy do human beings speak so many languages?<figure><img src="https://images.theconversation.com/files/178173/original/file-20170713-11780-17ip7zb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People currently speak 7,000 languages around the globe.</span> <span class="attribution"><span class="source">Michael Gavin</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>The thatched roof held back the sun’s rays, but it could not keep the tropical heat at bay. As everyone at the research workshop headed outside for a break, small groups splintered off to gather in the shade of coconut trees and enjoy a breeze. I wandered from group to group, joining in the discussions. Each time, I noticed that the language of the conversation would change from an indigenous language to something they knew I could understand, Bislama or English. I was amazed by the ease with which the meeting’s participants switched between languages, but I was even more astonished by the number of different indigenous languages.</p>
<p>Thirty people had gathered for the workshop on this island in the South Pacific, and all except for me came from the island, called Makelua, in the nation of Vanuatu. They lived in 16 different communities and spoke 16 distinct languages. </p>
<p>In many cases, you could stand at the edge of one village and see the outskirts of the next community. Yet the residents of each village spoke completely different languages. According to recent work by my colleagues at the <a href="http://www.shh.mpg.de/180082/dlce-research-projects">Max Planck Institute for the Science of Human History</a>, this island, just 100 kilometers long and 20 kilometers wide, is home to speakers of <a href="http://www.soundcomparisons.com/#/en/Malakula/map/one/Lgs_All">perhaps 40 different indigenous languages</a>. Why so many? </p>
<p>We could ask this same question of the entire globe. People don’t speak one universal language, or even a handful. Instead, today our species collectively speaks over <a href="https://www.ethnologue.com/">7,000 distinct languages</a>. </p>
<p>And these languages are not spread randomly across the planet. For example, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0107623">far more languages</a> are found in tropical regions than in the temperate zones. The tropical island of New Guinea is home to over 900 languages. Russia, 20 times larger, has 105 indigenous languages. Even within the tropics, language diversity varies widely. For example, the 250,000 people who live on Vanuatu’s 80 islands speak 110 different languages, but in Bangladesh, a population 600 times greater speaks only 41 languages.</p>
<p>Why is it that humans speak so many languages? And why are they so unevenly spread across the planet? As it turns out, we have few clear answers to these fundamental questions about how humanity communicates.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=491&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=491&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=491&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=617&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=617&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178175/original/file-20170713-9804-1u8y70s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=617&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Why do some places have many languages, and others only a few?</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Dgernesiais_welcome_sign_St_Peter_Port_Guernsey.jpg">Man vyi</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Some ideas, but little evidence</h2>
<p>Most people can easily brainstorm possible answers to these intriguing questions. They hypothesize that language diversity must be about history, cultural differences, mountains or oceans dividing populations, or old squabbles writ large – “we hated them, so we don’t talk to them.”</p>
<p>The questions also seem like they should be fundamental to many academic disciplines – linguistics, anthropology, human geography. But, starting in 2010, when <a href="https://www.nescent.org/science/awards_summary.php-id=255.html">our diverse team</a> of researchers from six different disciplines and eight different countries began to review what was known, we were shocked that only a dozen previous studies had been done, including one we ourselves completed on <a href="https://doi.org/10.1111/j.1466-8238.2011.00744.x">language diversity in the Pacific</a>.</p>
<p><a href="https://doi.org/10.1525/bio.2013.63.7.6">These prior efforts</a> all examined the degree to which different environmental, social and geographic variables correlated with the number of languages found in a given location. The results varied a lot from one study to another, and no clear patterns emerged. The studies also ran up against many methodological challenges, the biggest of which centered on the old statistical adage – correlation does not equal causation.</p>
<p>We wanted to know the exact steps that led to so many languages forming in certain places and so few in others. But previous work provided few robust theories on the specific processes involved, and the methods used did not get us any closer to understanding the causes of language diversity patterns.</p>
<p>For example, previous studies pointed out that <a href="https://doi.org/10.1371/journal.pone.0107623">at lower latitudes</a> languages are often spoken across smaller areas than at higher latitudes. You can fit more languages into a given area the closer you get to the equator. But this result does not tell us much about the processes that create language diversity. Just because a group of people crosses an imaginary latitudinal line on the map doesn’t mean they’ll automatically divide into two different populations speaking two different languages. Latitude might be correlated with language diversity, but it certainly did not create it. </p>
<h2>Can a simple model predict reality?</h2>
<p>A better way to identify the causes of particular patterns is to simulate the processes we think might be creating them. The closer the model’s products are to the reality we know exists, the greater the chances are that we understand the actual processes at work. </p>
<p>Two members of our group, ecologists <a href="https://scholar.google.com/citations?user=EHbuZpYAAAAJ">Thiago Rangel</a> and <a href="http://viceroy.eeb.uconn.edu/Colwell/">Robert Colwell</a>, had developed this <a href="https://doi.org/10.1098/rstb.2010.0293">simulation modeling technique</a> for their studies of <a href="https://doi.org/10.1086/521315">species diversity patterns</a>. But no one had ever used this approach to study the diversity of human populations.</p>
<p><a href="https://doi.org/10.1111/geb.12563">We decided to explore its potential</a> by first building a simple model to test the degree to which a few basic processes might explain language diversity patterns in just one part of the globe, the continent of Australia. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177774/original/file-20170711-14452-167eqee.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Map of Australia’s 406 languages before contact with Europeans.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1111/geb.12563">Claire Bowern, Yale University, with support from the National Science Foundation BCS-1423711</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Our colleague <a href="https://theconversation.com/profiles/claire-bowern-1098">Claire Bowern</a>, a linguist at Yale University, created a map that shows the diversity of aboriginal languages – a total of 406 – found in Australia prior to contact with Europeans. There were far more languages in the north and along the coasts, with relatively few in the desert interior. We wanted to see how closely a model, based on a simple set of processes, could match this geographic pattern of language diversity. </p>
<p>Our simulation model made only three basic assumptions. First, populations will move to fill available spaces where no one else lives.</p>
<p>Second, rainfall will limit the number of people that can live in a place; Our model assumed that people would live in higher densities in areas where it rained more. <a href="http://onlinelibrary.wiley.com/store/10.1111/geb.12563/asset/supinfo/geb12563-sup-0002-suppinfo2.pdf?v=1&s=b92a15ea48c3a0d9f85c9bd2e3731a1162917e89">Annual precipitation varies widely in Australia</a>, from over three meters in the northeastern rainforests to one-tenth of a meter in the Outback. </p>
<p>Third, we assumed that human populations have a maximum size. <a href="http://dx.doi.org/10.1037/1089-2699.12.1.7">Ideal group size</a> is a trade-off between benefits of a larger group (wider selection of potential mates) and <a href="https://doi.org/10.1016/0278-4165(90)90009-3">costs</a> (keeping track of unrelated individuals). In our model, when a population grew larger than a maximum threshold – set randomly based on a global distribution of hunter-gatherer population sizes – it divided into two populations, each speaking a distinct language.</p>
<p>We used this model to simulate language diversity maps for Australia. In each iteration, an initial population sprung up randomly somewhere on the map and began to grow and spread in a random direction. An underlying rainfall map determined the population density, and when the population size hit the predetermined maximum, the group divided. In this way, the simulated human populations grew and divided as they spread to fill up the entire Australian continent.</p>
<p>Our simple model didn’t include any impact from contact among groups, changes in subsistence strategies, the effects of the borrowing of cultural ideas or components of language from nearby groups, or many other potential processes. So, we expected it would fail miserably. </p>
<p>Incredibly, the model produced 407 languages, just one off from the actual number.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=570&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=570&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=570&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=716&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=716&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177760/original/file-20170711-26274-z0c5mn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=716&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The simulation model predicts virtually the same number of languages (407) as were observed in reality (406).</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1111/geb.12563">Gavin et al DOI: 10.1111/geb.12563</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The simulated language maps also show more languages in the north and along the coasts, and less in the dry regions of central Australia, mirroring the geographic patterns in observed language diversity.</p>
<p>And so for the continent of Australia it appears that a small number of factors – limitations rainfall places on population density and limits on group size – might explain both the number of languages and much of the variation in how many languages are spoken in different locations. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178176/original/file-20170713-5760-cvw5nj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A simulation model based on a few simple processes predicts much of the geographic variation in language diversity in Australia.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1111/geb.12563">Gavin et al DOI: 10.1111/geb.12563</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Applying the model elsewhere</h2>
<p>But we suspect that the patterns of language diversity in other places may be shaped by different factors and processes. In other locations, such as Vanuatu, rainfall levels do not vary as widely as in Australia, and population densities may be shaped by other environmental conditions.</p>
<p>In other instances, contact among human groups probably reshaped the landscape of language diversity. For example, the <a href="https://doi.org/10.1126/science.1078208">spread of agricultural groups</a> speaking Indo-European or Bantu languages may have changed the structure of populations and the languages spoken across huge areas of Europe and Africa, respectively.</p>
<p>Undoubtedly, a wide variety of social and environmental factors and processes have contributed to the patterns in language diversity we see across the globe. In some places topography, climate or the density of key natural resources may be more critical; in others the history of warfare, political organization or the subsistence strategies of different groups may play a bigger role in shaping group boundaries and language diversity patterns. What we have established for now is a template for a method that can be used to uncover the different processes at work in each location.</p>
<p>Language diversity has played a key role in shaping the interactions of human groups and the history of our species, and yet we know surprisingly little about the factors shaping this diversity. We hope other scientists will become as fascinated by the geography of language diversity as our research group is and join us in the search for understanding why humans speak so many languages.</p><img src="https://counter.theconversation.com/content/75434/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Funding from the National Evolutionary Synthesis Center, the Max Planck Institute for the Science of Human History, and the National Science Foundation to Michael Gavin (BCS-1660465) and Claire Bowern (BCS-1423711) supported the research discussed in this article.</span></em></p>There’s little research into origins of the geographic patterns of language diversity. A new model exploring processes that shaped Australia’s language diversity provides a template for investigators.Michael Gavin, Associate Professor of Human Dimensions of Natural Resources, Colorado State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/801272017-07-12T00:35:49Z2017-07-12T00:35:49ZWould impeaching Trump restore the rule of law? Lessons from Latin America<p>Some Americans and members of Congress have <a href="http://www.salon.com/2017/07/03/taking-it-to-the-streets-thousands-march-to-impeach-trump/">called for the impeachment</a> of President Donald Trump. </p>
<p>What happens after a president is impeached?</p>
<p>The vice president would take his place, but other parts of the government continue unchanged. That may not be a bad thing. However, partisan polarization can be magnified in the process. Many Americans already think the government is <a href="http://www.people-press.org/2017/04/17/3-views-of-congress/">too divided along partisan lines</a> and that <a href="http://www.rasmussenreports.com/public_content/politics/general_politics/june_2017/for_sale_congress">corruption</a> has reached <a href="https://www.washingtonpost.com/local/dc-politics/dc-and-maryland-to-sue-president-trump-alleging-breach-of-constitutional-oath/2017/06/11/0059e1f0-4f19-11e7-91eb-9611861a988f_story.html">the highest levels of government</a>. These beliefs fuel <a href="http://www.npr.org/2015/11/23/457063796/poll-only-1-in-5-americans-say-they-trust-the-government">declines in public trust</a> and <a href="http://www.gallup.com/poll/208526/adults-name-government-dissatisfaction-important-problem.aspx">dissatisfaction</a> with the government in general.</p>
<p>In my book on the <a href="https://www.cambridge.org/core/books/achilles-heel-of-democracy/729655118E5C21315EA768CE19291434">rule of law in Central America</a>, I discuss several occasions in which presidents were removed from office before their terms ended. The current political crisis in the United States shares similarities with political issues in Latin America. We are seeing <a href="http://www.people-press.org/2016/06/22/partisanship-and-political-animosity-in-2016/">radical partisanship</a>, <a href="http://www.pewresearch.org/data-trend/political-attitudes/congressional-favorability/">public dissatisfaction</a> and <a href="http://www.rasmussenreports.com/public_content/politics/mood_of_america/right_direction_wrong_track_jun26">perceived poor government performance</a>. Since only one U.S. president has left office due to wrongdoing, examples from Latin America can give us some perspective. </p>
<p>Lasting <a href="https://www.brookings.edu/blog/brookings-now/2015/05/06/40-years-ago-church-committee-investigated-americans-spying-on-americans/">reforms after Watergate</a> came from a <a href="https://www.senate.gov/artandhistory/history/common/investigations/ChurchCommittee.htm">Congressional committee’s investigation</a> and recommendations, rather than from the simple resignation of President Nixon. Impeachment is <a href="https://theconversation.com/impeachment-its-political-77528">inherently political</a> and, as I have observed in Latin America, does more to punish enemies than clean up politics. Removing a president who is a “bad apple” may help, but a real cleansing takes more effort.</p>
<h2>After impeachment</h2>
<p>Take Brazil as a case in point. Former President Dilma Rousseff <a href="https://www.theguardian.com/world/2016/aug/31/dilma-rousseff-impeached-president-brazilian-senate-michel-temer">was impeached</a> in 2016 in the midst of an anti-corruption investigation known as “Operation Car Wash.” There were already pending corruption investigations against <a href="http://www.latimes.com/world/mexico-americas/la-fg-brazil-impeach-20160328-story.html">37 of 65 members of the congressional impeachment commission</a>, but none of them were forced from office. It is no surprise that Rousseff’s impeachment appeared to many to be <a href="https://www.theguardian.com/global-development/2016/jul/05/in-brazil-women-are-fighting-against-the-sexist-impeachment-of-dilma-rousseff">inspired by sexism</a> rather than just anti-corruption efforts.</p>
<p>Rousseff’s replacement, President Michel Temer, <a href="https://www.reuters.com/article/us-brazil-corruption-idUSKBN19J2R5">was charged with</a> corruption-related offenses in June 2017. However, Temer’s political party and their allies control the majority of the Congress and the president of the Congress is an ally of Temer’s. A formal impeachment is unlikely to go forward.</p>
<p>We see a similar failure to pull out the root of corruption in the “Guatemalan Spring” of September 2015. Then Guatemalan President Otto Pérez Molina was forced to resign in the face of massive popular protests. He was implicated in an investigation into corruption at the national customs agency, for which he was arrested the day after his resignation. He had also been accused of <a href="http://www.bbc.com/news/world-latin-america-36060524">taking bribes from a Spanish firm</a> in exchange for granting it a lucrative long-term contract with the government of Guatemala.</p>
<p>An election was held just four days after Pérez Molina’s resignation. Jimmy Morales, a television comedian with no political experience, won the presidency over a former first lady. Morales ran as an outsider with the slogan “not corrupt, not a thief.” After his first year in office, <a href="http://www.telesurtv.net/english/news/Guatemalan-President-Jimmy-Morales-Marks-Inefficient-1st-Year-20170112-0017.html">which opponents have derided as “inefficient,”</a> Morales is also <a href="http://www.reuters.com/article/us-guatemala-corruption-idUSKBN16E2PW">facing a corruption scandal</a> involving accusations that his son and brother had fraudulent dealings with a government agency.</p>
<p>Take an older example, from Honduras. The <a href="http://harvardpolitics.com/united-states/us-honduran-coup/">military coup against Honduran President Manuel Zelaya in 2009</a> was authorized by that country’s Supreme Court and was backed by <a href="http://www.nytimes.com/2009/06/29/world/americas/29honduras.html">the majority of its Congress</a>. The Honduran Supreme Court argued that Zelaya was planning to reform the constitution to give himself more power as Venezuelan President Hugo Chavez had done. </p>
<p>Some eight years after Zelaya was removed, Honduran political elites continue to <a href="http://www.insightcrime.org/news-analysis/corruption-honduras-result-of-functioning-system-report">participate in widespread corruption</a>, including <a href="http://www.insightcrime.org/investigations/honduras-elites-and-organized-crime-introduction">direct ties between some political elites and organized crime</a>. Because so many of the elites are corrupt, none of them <a href="http://carnegieendowment.org/2017/05/30/when-corruption-is-operating-system-case-of-honduras-pub-69999">rock the boat.</a> </p>
<p>Even prosecuting and jailing presidents for corruption doesn’t seem to solve the problems that lead up to these crises. Often the rest of government continues to be overly partisan and even corrupt – and public satisfaction with government drops even lower. </p>
<p>In <a href="http://news.bbc.co.uk/2/hi/americas/3299289.stm">Nicaragua</a> and <a href="http://www.nytimes.com/2011/04/28/world/americas/28fbriefs-EXPRESIDENTF_BRF.html">Costa Rica</a>, for example, former presidents have been jailed on corruption charges, but those convictions were <a href="http://www.nytimes.com/2009/11/16/world/americas/16nicaragua.html">ultimately</a> <a href="http://www.ticotimes.net/2015/12/05/appeal-court-acquitts-ex-costa-rica-president-miguel-angel-rodriguez">overturned</a> on appeal. In 2013, Guatemala became the <a href="http://www.cnn.com/2013/05/10/world/americas/guatemala-genocide-trial/index.html">first country</a> to convict a former head of state of genocide in a national court. Ten days later, the Guatemalan Constitutional Court <a href="http://www.bbc.com/news/world-latin-america-22605022">reversed</a> General Efraín Rios Montt’s conviction over an evidentiary matter – although 2017 may yet see a <a href="https://www.ijmonitor.org/2017/04/rios-montt-to-face-second-genocide-trial-for-the-dos-erres-massacre/">new trial</a>. The point is, it is extraordinarily difficult to make charges stick against even a former president, especially if he or she still has sizable support in the government.</p>
<h2>Beyond impeachment</h2>
<p>Problems with governance are rarely fixed by going after even an unpopular or corrupt president if fundamental institutional problems are allowed to continue unchecked. Impeachment’s weakness is compounded by its often partisan deployment. </p>
<p>What else can be done to clean up politics? </p>
<p>The hard work of demanding <a href="https://www.foreignaffairs.com/articles/brazil/2017-04-13/brazil-s-never-ending-corruption-crisis">transparency</a> more generally may help get at the root of the problem. Progress in Guatemala has been buoyed by an <a href="https://www.cfr.org/report/lessons-guatemalas-commission-against-impunity">international anti-corruption commission</a> that has helped local officials shine a light on official wrongdoing at every level of government. </p>
<p>Ultimately, using <a href="https://www.foreignaffairs.com/articles/brazil/2017-06-02/brazils-best-shot-against-corruption">legal channels to improve political institutions</a>, rather than focusing on just one bad politician, can enhance the rule of law.</p><img src="https://counter.theconversation.com/content/80127/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel E. Bowen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ousting an executive leader from office doesn’t always have the intended effect, as these examples from Central and South America show.Rachel E. Bowen, Associate Professor of Political Science, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722422017-07-04T23:02:02Z2017-07-04T23:02:02ZWe’re not ready for the ‘silver tsunami’ of older adults living with cancer<figure><img src="https://images.theconversation.com/files/171838/original/file-20170601-25704-9fkx9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of adults living with cancer will likely triple in size by 2030.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/234242599?src=9d1geb1Zo7b72MzCAt7u9g-2-70&size=huge_jpg">Ruslan Guzov/Shutterstcok.com</a></span></figcaption></figure><p>In the next few decades, the number of adults living with cancer is expected to <a href="http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2014.55.8361">triple in size</a>.</p>
<p>Age is the single greatest risk factor for cancer. By 2030, according to the Centers for Disease Control and Prevention, the population of Americans over the age of 65 <a href="https://www.cdc.gov/aging/pdf/State-Aging-Health-in-America-2013.pdf">will double</a>.</p>
<p>The good news is that early detection, innovative treatments and supportive care have turned many cancers into chronic illnesses, one disease among other chronic health conditions that older adults may experience. But these coexisting health conditions are likely to complicate the treatment and management of older adults’ cancer. </p>
<p>Our current understanding of appropriate care for older adults with cancer and their unique needs is limited. As an expert in cancer survivorship and aging, I see several specific areas that warrant our attention. </p>
<h1>Generational differences</h1>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171854/original/file-20170601-25658-jy9gsz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In 2009, Morton Genser, who was 72 at the time, took multiple pills a day to regulate his diabetes, blood pressure and other illnesses.</span>
<span class="attribution"><span class="source">AP Photo/Wilfredo Lee</span></span>
</figcaption>
</figure>
<p>Cancer in older adults is complex. For the elderly, cancer is often <a href="http://www.futuremedicine.com/doi/abs/10.2217/1745509X.3.5.625?journalCode=ahe&">one of several coexisting health conditions</a> that they may be managing, such as heart disease, arthritis or diabetes. Eighty percent of older adults with cancer report two or more additional health conditions. One in four cancer survivors between 65 and 74 years old have more than five concurrent health conditions.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21402176">Older adults with multiple chronic conditions</a> are more likely to have poorly coordinated care, adverse interactions between medications and worse health outcomes. They also tend to use more health care services and, on average, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785194/">take six or more</a> prescription medications. </p>
<p>In older adults, the late health effects of cancer can be different or exacerbated by age. For example, cancer-related fatigue, reductions in cognitive function and chemotherapy-induced peripheral neuropathy <a href="http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2014.55.8361">can pose unique issues</a>. The interplay between these treatment-related effects and common age-related issues presents challenges for care of older adults with cancer.</p>
<p>The psychological and social experience of cancer can also differ markedly for young and older adults. Roles, responsibilities and support systems change as people age. Many young adults with cancer are dealing with competing demands of work or family. Having fewer demands as an older adult might make the disease more manageable in some respects. </p>
<p>But a decrease in social networks and support – such as retirement or living farther away from family – may have negative effects. Many older adults will <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799049/">minimize their distress</a>, so not to burden their families and caregivers. This leads to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052769/">underdiagnosis</a> of treatable distress. </p>
<p>These effects can be exacerbated by health care providers with competing priorities, short office visits and no organizational support for psychosocial distress screening. </p>
<h1>Health care providers</h1>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK215395/">In 2008</a>, the National Academy of Medicine warned of a looming shortage of geriatric oncologists and nurses, as well as a lack of interest among medical professionals in geriatric oncology. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/20859376">number of oncology office visits</a> required by older adults with cancer is projected to surpass the available oncologic workforce by 2020. What’s more, older adults may see <a href="https://www.cdc.gov/aging/pdf/State-Aging-Health-in-America-2013.pdf">up to 12 different health care specialists</a> in a given year. </p>
<p>Who should coordinate this care? Oncologists are experts in the diagnosis and treatment of cancer, but many older adults have competing health concerns that require more than just an oncologist. Geriatricians are trained in managing multiple health conditions and optimizing functional performance in older adults, but may be less familiar with managing cancer. </p>
<p>We need to make a concerted effort to foster collaborative care partnerships between geriatricians and oncology – including geriatric nurses in both fields, as they are on the front lines interacting with older cancer patients. A team of health professionals could jointly share responsibility for managing the health of older adults with cancer, exchanging patient data and information between the team. </p>
<p>Research shows that <a href="https://www.ncbi.nlm.nih.gov/pubmed/21402176">this type of collaborative model</a> leads to better cancer follow-up care, health outcomes and effective management of coexisting health conditions. </p>
<h1>Focus on the family</h1>
<p>Cancer is a disease that reverberates across the family system, leaving no one untouched. In fact, research suggests that caregivers and family members often <a href="https://www.researchgate.net/publication/285549457_Assessing_cancer-related_distress_in_cancer_patients_and_caregivers_receiving_outpatient_psycho-oncological_counseling">report higher levels of distress</a> than does the individual with cancer. </p>
<p>With more and more cancer care delivered on an outpatient basis, coupled with the changing nature of cancer as a chronic disease, there is a growing burden on family to help a loved one manage their disease. Moreover, many older family members may themselves be dealing with a chronic illness and other life stressors, adding to the burden. </p>
<p>Research suggests that providing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791523/">psychological and educational support</a> for cancer caregivers and family members may improve not only the health of patients, but the health of caregivers. </p>
<h1>What’s next?</h1>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171860/original/file-20170601-25684-195dvzk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Care for older adults is becoming more limited.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/andyde/4762068019/in/photolist-8fNQV2-hrya4W-8tN7X7-gXKh8i-TPrMvz-7x2adB-dQwLK4-SFHbSa-9EcfT2-VaJTtf-8GVwpa-7bUSd6-9DJPBM-TzuM9Y-xPuKc-7zdGfi-7bYRvN-dgZUG3-TemLG9-Temnqu-4R4JgR-fAAPfh-8CSH8u-9XF7ag-bb3f8k-4djzh2-TWP65Y-dQwLH6-7LdJSB-f3aFLv-pcEc3L-7bYHHQ-aCZwBo-7bUYoa-6cKCFj-8tN895-T8JU9w-osemh-UVFBg1-omnJ9H-oUsA4-SHqXs1-brvFo-5ZykLS-qddPij-2kiJtH-8pyT3t-2kiJzH-2jmYLG-EptQv">Andyde/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
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<p>Planning for the health care needs of our aging cancer survivors represents a significant public health challenge.</p>
<p>What we know about caring for cancer survivors is largely based on the experiences of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26278341">adult survivors of child-onset cancer</a> and proactive groups of middle-aged breast cancer survivors. There is an urgent need for additional research on the needs and care of the burgeoning geriatric population. </p>
<p>In 2010, the U.S. Department of Health and Human Services <a href="https://www.hhs.gov/sites/default/files/ash/initiatives/mcc/mcc_framework.pdf">released a report on multiple chronic conditions</a>. It recommended including older adults with multiple chronic conditions in clinical trials, facilitating self-care management and promoting multiple chronic condition curricula in the health care sector. It also suggested educating the federal, private and public sectors about issues related to multiple chronic conditions.</p>
<p>While this national initiative is encouraged, it’s clear that the growing number of older adults with cancer outpaces current efforts. If we want to successfully respond to the demand, we must find ways to quickly conduct meaningful and targeted research on this unique population. This can help us develop best practices and offer high-quality care.</p><img src="https://counter.theconversation.com/content/72242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith M. Bellizzi receives funding from the National Cancer Institute and the University of Connecticut.</span></em></p>The number of adults living with cancer is expected to triple in size by 2030. How can we prepare for this public health challenge?Keith M. Bellizzi, Associate Professor of Human Development and Family Studies, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/800302017-07-02T15:23:31Z2017-07-02T15:23:31ZHow Spam became one of the most iconic American brands of all time<figure><img src="https://images.theconversation.com/files/176273/original/file-20170629-16083-1xnit1l.jpg?ixlib=rb-1.1.0&rect=0%2C208%2C2578%2C1956&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eight billion cans sold and counting...</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/leeds-united-kingdom-july-5th-2011-171401612?src=gZRd7Ib0oHQ74_vj8wdbTw-1-8">abimages/Shutterstock.com</a></span></figcaption></figure><p>While you might think of Spam as a basic canned meat, it’s actually one of the greatest business success stories of all time: Since <a href="http://www.hormelfoods.com/">Hormel Foods Corporation</a> launched the affordable, canned pork product in 1937, it’s sold over <a href="http://www.spam.com/about">eight billion cans</a> in 44 countries around the world. </p>
<p>Spam’s birthday is July 5th. It’s fitting that this comes only a day after the birthday of the United States. The product is up there with Coca-Cola, McDonald’s and Pizza Hut as one of the most distinctive American brands of all time.</p>
<p>As a consumer behavior researcher, I believe Spam’s widespread success can be attributed to two factors: it addressed a real need, and also formed an emotional connection with its consumers, by tapping into American ideals like ingenuity and resourcefulness.</p>
<h2>Spam ‘hits the spot’</h2>
<p>Spam isn’t exactly the most exciting product.</p>
<p>The original recipe included chopped pork shoulder meat with ham, salt, water, sugar and sodium nitrite. (This remained unchanged until 2009, when Hormel <a href="https://www.eater.com/2014/7/9/6191681/a-brief-history-of-spam-an-american-meat-icon">added potato starch</a> in an effort to eliminate one of the product’s less attractive features: the gelatin layer created by the cooking process.) At the time it was introduced, it was the only canned meat product on the market that needed no refrigeration. This feature gave Spam a significant competitive advantage.</p>
<p>Hormel also created buzz around its new product by sponsoring a name contest to promote it. </p>
<p>The winner was an actor named <a href="https://powersbehindgr.wordpress.com/powers-theatre/stock-theatre/broadway-players/kenneth-daigneau/">Kenneth Daigneau</a>, who was awarded US$100 for coming up with the name “Spam.” (He was also the brother of Hormel’s vice president, so there may have been a bit of nepotism involved.) </p>
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<a href="https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=867&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=867&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=867&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1089&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1089&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176269/original/file-20170629-28236-r06ggm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1089&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">‘Cold or hot…Spam hits the spot!’</span>
<span class="attribution"><a class="source" href="https://c1.staticflickr.com/8/7368/12915784114_0d0869810f_b.jpg">Classic Film/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
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<p>Anointed with its new name, the product was buoyed by a heavy advertising effort that emphasized its versatility. For example, in 1940, <a href="https://books.google.com/books?id=A0AEAAAAMBAJ&pg=PA105&lpg=PA105&dq=original+uses+of+SPAM&source=bl&ots=2dqBSMJTD7&sig=yZkNq1OG1YD2awWWDzN-8ouzLRo&hl=en&sa=X&ved=0ahUKEwje1J3a-OXUAhWDOz4KHSh0CXMQ6AEIYDAJ#v=onepage&q=original%20uses%20of%20SPAM&f=false">Hormel fielded submissions</a> from Spam fans to create a 20-page recipe book featuring 50 ways of incorporating the canned meat into meals.</p>
<p>Homemakers readily embraced Spam, and it became a popular lunch and breakfast meat. But sales really took off during World War II. Over 150 million pounds were <a href="http://www.artofmanliness.com/2015/01/20/americas-miracle-meat-the-story-of-spam-3-recipes/">used in the war effort</a>, making Spam a cornerstone of troops’ diets. (Soldiers also used Spam’s grease <a href="https://books.google.com/books?id=i0mAQgAACAAJ&dq=SPAM:+a+biography&hl=en&sa=X&ved=0ahUKEwjpk4SCgebUAhUEFT4KHTD9BYUQ6AEIJjAA">to lubricate their guns and waterproof their boots</a>.) In each country where they were stationed, American soldiers introduced it to the locals, giving foreigners their first taste of Spam. </p>
<p>Since then, Spam has become a sought-after product in many countries around the world, especially those that have faced economic hardship. Because it’s cheap, filling and has a long shelf life, it addresses a real need. </p>
<h2>As American as apple pie?</h2>
<p>But how did it become such a cultural icon?</p>
<p><a href="http://www.msi.org/articles/the-seven-dimensions-of-brand-love/">In a 2012 paper</a>, marketing researchers Rajeev Batra, Aaron Ahuvia and Richard P. Bagozzi developed a model of “brand love.” Based on studies on consumers’ brand attachment, they showed that in order to form meaningful attachment with brands, consumers need to experience them in ways beyond simply buying and using the product. </p>
<p>Hormel seemed to intuitively understand these ideas. Simply selling a cheap, useful product wouldn’t be enough. In creative and humorous ways that went beyond traditional advertising, they appealed to consumers by positioning the brand as a patriotic food that reflected American ingenuity – with a streak of eccentricity. </p>
<p>In the years after the war, the Hormel Girls – <a href="https://www.youtube.com/watch?v=f3kwbEL8LY4">a musical troupe of female World War II veterans</a> – traveled the country performing songs and promoting the product. The group even starred in a top-rated radio show on three national networks.</p>
<p>Since then, the Spamarama cooking festival (1976-2007), a Spam museum (1991), a Spam recipe contest (1991), a Spam-sponsored NASCAR race car (1995) and even a 2005 Broadway musical – “Spamalot” – all enhanced what’s called the <a href="https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfiles/4243/Brand%20Experience%20and%20Loyalty_Journal_of%20_Marketing_May_2009.pdf">brand experience</a>, the way consumers interact and connect with a product. </p>
<p>These marketing ventures were accompanied by the introduction of new products and flavors. The Spamburger (1992), Spam Lite with 50 percent less fat (1995), Spam Hot and Spicy (2000), Spam with Bacon (2004), Spam Teriyaki and Spam Jalapeño (2012) reflected consumers’ evolving tastes and preferences. Spam Spread was even introduced just in case you’re “a spreader, not a slicer.” </p>
<h2>Refashioning Spam in the 21st century</h2>
<p>In other cultures around the world, Spam is viewed as a distinctly American product, though it’s been incorporated into local cuisine in creative ways. In Hawaii – <a href="http://www.huffingtonpost.com/Menuism/why-do-hawaiians-love-spam-so-much_b_1901306.html">where seven million cans are sold each year</a> – McDonald’s franchises <a href="https://www.mcdonalds.com/us/en-us/product/spam-eggs-and-rice.html">will offer Spam-based products</a>, like Spam, eggs and rice. The <a href="http://allrecipes.com/recipe/49785/spam-musubi/">Spam Musubi</a> – Spam on rice wrapped in seaweed – is also a popular snack and lunch food.</p>
<p>In South Korea, Spam is considered a <a href="https://www.nytimes.com/2014/01/27/world/asia/in-south-korea-spam-is-the-stuff-gifts-are-made-of.html">popular holiday gift</a>, while in the U.K., the <a href="https://theenglishkitchen.blogspot.com/2011/05/spam-fritters.html">Spam fritter</a> is served with chips and mushy peas in burger bars. In the Philippines, <a href="http://www.filipinochow.com/spamsilog/">Spamsilog</a> is a common breakfast meal of Spam, fried rice and sunny-side up egg. </p>
<p>Back in the United States, restaurateurs have seized upon Spam’s place in the cultural imagination to (somewhat ironically) incorporate the product in refined dishes. At San Francisco’s <a href="http://liholihoyachtclub.com/">Liholiho Yacht Club</a>, you can get Spam fried rice with uni and mushrooms. <a href="http://www.animalrestaurant.com/">Animal</a> in Los Angeles offers foie gras and Spam, while New York City’s <a href="http://www.noreetuh.com">Noreetuh</a> serves Spam agnolotti with burgundy truffles. It was even <a href="http://ew.com/recap/top-chef-new-orleans-maui/">featured in a culinary challenge</a> on Season 11 of Top Chef. </p>
<p>When Spam was first introduced, Hormel was eager to promote the product’s versatility with <a href="http://gaia.adage.com/images/bin/image/medium/0429p28--SPAM-Burns-and-Allen-2x3.jpg?1366906973">taglines</a> like “Cold or hot…Spam hits the spot.”</p>
<p>But with the canned meat moving from the front lines of World War II to $40 entrees at high-end restaurants, its various incarnations have likely surpassed its inventors’ wildest visions.</p><img src="https://counter.theconversation.com/content/80030/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayalla A. Ruvio does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Over 80 years ago, Hormel Foods introduced a simple, canned meat product called Spam. It would go on to become one of the greatest marketing success stories of all time.Ayalla A. Ruvio, Assistant Professor of Marketing, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/789062017-06-07T01:33:08Z2017-06-07T01:33:08ZWhy have other Gulf states cut ties with Qatar?<figure><img src="https://images.theconversation.com/files/172568/original/file-20170606-3677-1533bvt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The skyline of Doha, Qatar.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File%3AWest_Bay_Skyline%2C_Doha%2C_State_of_Qatar.jpg">Gregory Hawken Kramer</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Gulf Arab countries summon images of oil-fueled wealth, luxurious malls and strong Muslim identity. Nasty regional rivalry, diplomatic ruptures and panicked citizens <a href="https://www.zawya.com/mena/en/story/Qatar_residents_stockpile_food_as_Saudi_plans_to_close_land_border-ZAWYA20170605103702/">stockpiling groceries</a> don’t usually figure.</p>
<p>So why have Gulf states Bahrain, Saudi Arabia, the United Arab Emirates (UAE) and Yemen, as well as non-Gulf Egypt, dramatically ruptured relations with tiny Qatar? What will this international crisis mean for the Middle East and the broader world?</p>
<h2>What is the dispute about?</h2>
<p>The Arab Gulf spans diverse countries. On one end of the scale is <a href="http://www.worldbank.org/en/country/yemen/overview">fractured, war-torn Yemen</a>. Then come the tourist destination and politically unassertive Oman, the small oil kingdoms of Bahrain, Kuwait, Qatar and the UAE, and regional powerhouse Saudi Arabia. </p>
<p>As the largest country in the Arab Gulf, Saudi Arabia has long championed common regional policies under its leadership. However, in the past few decades, the rapid growth of massive oil wealth in smaller countries like Qatar and the UAE has allowed them excess capital to establish their own global influence.</p>
<p>The UAE has largely aligned its foreign policy with its larger neighbor. But Qatar has used its wealth to adopt policies different from, and sometimes rivaling, Saudi Arabia’s. Qatari positions have been propelled through the <a href="http://www.aljazeera.com/aboutus/">Al-Jazeera</a> media network, based in Qatar’s capital, Doha, <a href="http://www.independent.co.uk/news/media/al-jazeera-block-article-slamming-saudi-arabian-human-rights-record-a6779596.html">partially funded</a> by Qatar’s ruling family, and <a href="https://www.brookings.edu/articles/al-jazeera-the-most-feared-news-network/">popular throughout the Middle East.</a></p>
<p>The Saudis have not appreciated Qatar’s foreign policy assertions, particularly its warmer relations with their archrival Iran. In Syria’s civil war, Qatar and Saudi Arabia both oppose ruler Bashar al Assad, but have supported competing Sunni militias. Qatar also had <a href="http://www.thenational.ae/world/qatar/inside-doha-at-the-heart-of-a-gcc-dispute">good relations with the freely elected Muslim Brotherhood government in Egypt</a> and other anti-establishment Islamist organizations, again in contrast to Saudi positions.</p>
<p>The 2013 removal by the military of Egypt’s Muslim Brotherhood government under President Mohamed Morsi spearheaded a broader move among Arab governments to crack down on Sunni Islamist organizations that could threaten their authority. Some of these organizations <a href="http://www.huffingtonpost.com/giorgio-cafiero/the-uae-and-qatar-wage-a-_b_8801602.html">had received Qatari support</a>. </p>
<p>In 2014, to pressure Qatar to fall in line with Saudi-led policies, Saudi Arabia, Bahrain and the UAE suspended diplomatic ties with their neighbor. In response Qatar pulled back somewhat from open support for militant Sunni political groups and cooperation with Iran. It continued nonetheless to <a href="http://www.aljazeera.com/indepth/features/2014/03/will-gcc-survive-qatar-saudi-rivalry-201431864034267256.html">assert a right to its own foreign policy.</a> </p>
<h2>What prompted the current crisis?</h2>
<p>Relations improved modestly since 2014. But Saudi and other commentators still complained that Qatar was <a href="http://www.thenational.ae/opinion/comment/qatar-cannot-be-allowed-to-sabotage-the-region">“sabotaging the region</a>.”</p>
<p>And then came President Donald Trump’s May 21 visit to Riyadh, bolstering U.S. ties with Saudi Arabia and Egypt and promoting a common front against Iran and <a href="http://www.arabnews.com/node/1103136/saudi-arabia">Islamist “extremism,”</a> a vague term which for the Saudis can include political opposition groups like the Muslim Brotherhood.</p>
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<a href="https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172567/original/file-20170606-3674-1qo61fe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">On his recent trip to Saudi Arabia, President Donald Trump, right, met with Qatar’s Emir Sheikh Tamim Bin Hamad Al-Thani.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/US-Middle-East/5912b74b0fe3474d845b0ccb60dd1200/2/0">AP Photo/Evan Vucci</a></span>
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<p>Soon after, on May 24, Qatari news sites were blocked by Saudi Arabia and the UAE after alleged remarks by Qatar’s ruler <a href="https://www.theguardian.com/world/2017/may/25/saudi-arabia-and-uae-block-qatari-media-over-incendiary-statements-iran-israel">that openly acknowledged Iran’s regional political role and Qatari ties to Israel.</a> Arab Gulf leaders would not normally take such positions publicly. Qatari sources insisted that the remarks were inaccurate, and that <a href="https://www.usnews.com/news/world/articles/2017-05-23/qatar-says-its-official-state-news-agency-was-hacked">Doha’s media had been hacked</a>.</p>
<p>But Saudi Arabian and Emirati sources played up the alleged comments. They portrayed them as a renewed sign that Qatari policies remain deviant, despite the 2014 efforts to make Doha fall in line. The Trump administration’s <a href="http://www.cnbc.com/2017/05/20/us-saudi-arabia-seal-weapons-deal-worth-nearly-110-billion-as-trump-begins-visit.html">announcement of a large military sale to Saudi Arabia</a> suggests new assurance in Riyadh that Washington will back confrontation against Iran. This likely bolstered Saudi confidence that it could move to rein in Qatar.</p>
<h2>What is Qatar’s perspective?</h2>
<p>Qatar’s ambitious growth has included opening its society to global <a href="http://qatarphilharmonicorchestra.org/">cultural</a>, <a href="https://www.washingtonpost.com/local/education/in-qatars-education-city-us-colleges-are-building-an-academic-oasis/2015/12/06/6b538702-8e01-11e5-ae1f-af46b7df8483_story.html?utm_term=.0b78554f2a2a">educational</a> and business influences, as the country completes its plans to host <a href="https://www.theguardian.com/football/2017/jun/05/2022-world-cup-qatar-under-threat-saudi-arabia-blockade-fifa-football">soccer’s 2022 World Cup</a>. As part of this ambition, Qatar has asserted its intention to <a href="https://fsi.stanford.edu/sites/default/files/INTA89_2_10_Khatib.pdf">work with a range of global partners</a>. </p>
<p>This foreign policy has included <a href="https://www.brookings.edu/wp-content/uploads/2016/06/Final-PDF-English.pdf">mediating between Islamist groups and Arab governments</a>, as well as <a href="http://www.al-monitor.com/pulse/originals/2015/11/iran-qatar-rapprochement-middle-east.html">between Iran and other countries</a>. Although <a href="http://foreignpolicy.com/2017/05/22/qatar-needs-to-do-its-part/">some have critiqued</a> such an approach as two-faced, Qatari officials could argue that it is a rational strategy to resolve conflict in places where repressing Islamic political opposition <a href="https://www.brookings.edu/blog/markaz/2015/10/14/islamism-the-arab-spring-and-the-failure-of-americas-do-nothing-policy-in-the-middle-east/">has not worked</a>. </p>
<p>Whatever actually happened to trigger the crisis, <a href="http://www.dailymail.co.uk/wires/afp/article-4535914/Qatars-state-news-agency-hacked-unknown-entity.html">Qatar’s concerns about hacking</a>, <a href="https://english.alarabiya.net/en/views/news/2017/06/06/Qatar-s-ambition.html">recent Saudi and other critiques of the country</a>, and <a href="http://www.huffingtonpost.com/entry/leakers-share-new-email-dump-targeting-top-arab-diplomat-and-us-foreign-policy-elites_us_5934450be4b0c242ca252468">leaked emails from other Gulf governments</a> make Qataris feel victimized by what <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2017/06/01/whats-going-on-with-qatar/?utm_term=.4baf6d58fffe">could be a well-orchestrated campaign against them</a>. </p>
<h2>Why does this matter?</h2>
<p>Stability in the Arab Gulf region is <a href="https://gccstat.org/en/">critical to world trade</a>, <a href="https://en.wikipedia.org/wiki/List_of_busiest_airports_by_international_passenger_traffic">global transportation</a> and regional military security. Dubai, for example, has been the world’s <a href="http://www.telegraph.co.uk/travel/destinations/middle-east/united-arab-emirates/dubai/articles/The-incredible-rise-of-Dubai-as-the-worlds-air-travel-hub/">busiest airport by international passenger traffic for several years</a>, with Qatar’s Hamad Airport not far behind. And, with 11,000 U.S. troops on site, Qatar hosts the <a href="http://www.cnn.com/2017/06/05/middleeast/qatar-us-largest-base-in-mideast/index.html">Middle East’s major American military base</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172570/original/file-20170606-3681-11p0s9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The U.S. Al Udeid Air Base in Qatar.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/5/54/Al_Udeid_Air_Base.jpg">U.S. Government</a></span>
</figcaption>
</figure>
<p>The bottom line is that the dramatic escalation of tensions in the Arab Gulf threatens regional stability, and makes it much harder to resolve graver conflicts in Syria, Libya, Islamic State-controlled Iraq and Yemen. Indeed, Qatar’s isolation from other Arab states could lead it closer to Turkey or even Iran. </p>
<p>More generally, the move against Qatar is part of a broad regional shift since the Arab uprisings of 2011. Many Arab governments now feel justified in <a href="https://www.ifex.org/middle_east_north_africa/2017/06/04/repression-crush-dissent/">acting strong to quash dissent</a>. They are now more likely to condone <a href="http://www.france24.com/en/20170526-world-leaders-find-freedom-repress-era-trump">using force internally to maintain stability</a> and in <a href="http://foreignpolicy.com/2017/05/20/if-trump-doubles-down-on-the-saudi-war-in-yemen-millions-could-starve/">external conflicts like Yemen</a>. The Trump administration appears <a href="https://www.nytimes.com/2017/04/03/world/middleeast/-egypt-sisi-trump-white-house.html?_r=0">comfortable with this</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"872077638042628096"}"></div></p>
<p>Indeed, the President has inserted himself directly into the growing conflict in several tweets, pointing a finger at Qatar as a funder of “radical ideology.” The U.S. may end up mediating the dispute out of its own interest in regional stability and its military base. At the same time, Trump has revealed his support for the Saudi position, and the trend to curb dissenting Arab voices around regional policy.</p>
<p>This trend goes against Qatar’s past autonomy and policies, leaving it little wiggle room. Qatar may have no choice but to conform its policies to Saudi ones, and to limit Al-Jazeera’s independence. Whether or not the crisis resolves soon, Riyadh’s new move against Doha has underscored its clear <a href="http://www.newsweek.com/qatar-may-have-pay-heavy-price-restore-links-its-gulf-neighbors-620948">determination to limit Qatari policy influence as much as possible</a>.</p>
<p><em>Editor’s note: This article was updated to include President Trump’s statements – via Twitter – on Qatar.</em></p><img src="https://counter.theconversation.com/content/78906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Mednicoff received a Fulbright US-government fellowship to be a visiting professor in Qatar in 2006-7, a fellowship at Harvard University funded in part through the Dubai School of Government in the UAE, and a research grant from 2013-16 from the Qatar National Research Fund. He currently receives no external funding from any government or government-funded entity.</span></em></p>Qatar has used its wealth to adopt policies sometimes rivaling Saudi Arabia’s. Think, for example, of the popular Al-Jazeera. Now the Saudis seem determined to limit Qatari influence as much as possible.David Mednicoff, Director, Middle Eastern Studies, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/782162017-05-24T02:20:39Z2017-05-24T02:20:39ZWhat is the Shia-Sunni divide?<p>Tensions between Sunnis and Shias have been flaring up, with several incidents of violence reported in recent months: Most recently a suicide bomber killed at least 29 people when he blew himself up at the <a href="http://religionnews.com/2017/08/02/blast-at-shiite-mosque-in-afghanistan-kills-dozens/">largest Shiite Muslim mosque</a> in Afghanistan’s Herat province on Tuesday, August 1. </p>
<p>Earlier in June, the <a href="https://www.usnews.com/news/world/articles/2017-06-07/iranian-media-shooting-at-parliament-wounds-security-guard">Islamic State claimed responsibility</a> for two attacks that claimed at least 12 lives in Iran. Iran is a Shia Muslim majority state often in tension with Sunni states and <a href="https://www.cfr.org/backgrounder/islamic-state">extremist groups</a> like the Islamic State or al-Qaeda. </p>
<p>As a scholar of Islam and a public educator, I often field questions about Sunnis, Shias and the sects of Islam. What exactly is the Shia-Sunni divide? And what is its history?</p>
<h2>History of divide</h2>
<p>Both Sunnis and Shias – drawing their faith and practice from the Qur’an and the life of the Prophet Muhammad – agree on most of the fundamentals of Islam. The differences are related more to historical events, ideological heritage and issues of leadership. </p>
<p>The first and central difference emerged after the death of Prophet Muhammad in A.D. 632. The issue was who would be the caliph – the “deputy of God” – in the absence of the prophet. <a href="https://books.google.de/books?id=O36yXxCMiQIC&printsec=frontcover&dq=islam+a+brief+history&hl=en&sa=X&redir_esc=y#v=onepage&q&f=false">While the majority sided with Abu Bakr,</a> one of the prophet’s closest companions, a minority opted for his son-in-law and cousin – Ali. This group held that Ali was appointed by the prophet to be the political and spiritual leader of the fledgling Muslim community.</p>
<p>Subsequently, those Muslims who put their faith in Abu Bakr came to be called Sunni (“those who follow the Sunna,” the sayings, deeds and traditions of the Prophet Muhammad) and those who trusted in Ali came to be known as Shia (a contraction of <a href="https://books.google.de/books?id=9HUDXkJIE3EC&pg=PA16&dq=Shiat+Ali+Esposito+Islam&hl=en&sa=X&redir_esc=y#v=onepage&q=Shiat%20Ali%20Esposito%20Islam&f=false">“Shiat Ali,” meaning “partisans of Ali”</a>).</p>
<p>Abu Bakr became the first caliph and Ali became the fourth caliph. However, Ali’s leadership was challenged by Aisha, the prophet’s wife and daughter of Abu Bakr. Aisha and Ali went to battle against each other near Basra, Iraq in <a href="https://books.google.de/books?id=1nNjDQAAQBAJ&pg=PT130&dq=history+of+islam+battle+of+the+camel&hl=en&sa=X&redir_esc=y#v=onepage&q=history%20of%20islam%20battle%20of%20the%20camel&f=false">the Battle of the Camel in A.D. 656.</a> Aisha was defeated, but the roots of division were deepened. Subsequently, Mu’awiya, the Muslim governor of Damascus, <a href="https://books.google.de/books?id=1nNjDQAAQBAJ&pg=PT130&dq=history+of+islam+battle+of+the+camel&hl=en&sa=X&redir_esc=y#v=onepage&q=history%20of%20islam%20battle%20of%20the%20camel&f=false">also went to battle against Ali</a>, further exacerbating the divisions in the community. </p>
<p>In the years that followed, Mu’awiya assumed the caliphate and founded the Ummayad Dynasty (A.D 670-750). Ali’s youngest son, Hussein – born of Fatima, the prophet’s daughter – led a group of partisans in Kufa, Iraq against Mu’awiya’s son Yazid. For the Shias, this battle, known as <a href="https://books.google.de/books?id=egGgUM_YdL8C&pg=PA8&dq=the+battle+of+karbala&hl=de&sa=X&ved=0ahUKEwidyvaAvobUAhViIJoKHbmsBZQQ6AEIQTAF#v=onepage&q=the%20battle%20of%20karbala&f=false">the Battle of Karbala, holds enormous historical and religious significance.</a></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170634/original/file-20170523-5799-1pzvnhn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An Iranian Shiite Muslim mourns after covering herself with mud during Ashura rituals in Iran.</span>
<span class="attribution"><span class="source">AP Photo/Ebrahim Noroozi</span></span>
</figcaption>
</figure>
<p>Hussein was killed and his forces defeated. For the Shia community, Hussein became a martyr. The day of the battle is commemorated every year on <a href="https://books.google.de/books?id=6VeCWQfVNjkC&printsec=frontcover&dq=Ashura+Oxford+Encyclopedia+of+Islam&hl=en&sa=X&ved=0ahUKEwi1xvn2wIbUAhUFFywKHaBlAakQ6AEISzAH#v=snippet&q=Ashura&f=false">the Day of Ashura</a>. Held on the tenth day of Muharram in the Islamic lunar calendar, scores of pilgrims visit Hussein’s shrine in Karbala and many Shia communities participate in symbolic acts of flagellation and suffering.</p>
<h2>Leadership disagreements</h2>
<p>Over time, Islam continued to expand and develop into evermore complex and overlapping societies that spanned from Europe to sub-Saharan Africa, North Africa to Asia. This development demanded more codified forms of religious and political leadership. </p>
<p>Sunnis and Shias adopted different approaches to these issues.</p>
<p>Sunni Muslims trusted the secular leadership of the caliphs during the Ummayad (based in Damascus from A.D. 660-750) and Abbasid (based in Iraq from 750-1258 and in Cairo from 1261-1517) periods. Their theological foundations came from the four religious schools of Islamic jurisprudence that emerged <a href="https://www.academia.edu/2310961/The_background_and_formation_of_the_Four_Schools_of_Islamic_Law">over the seventh and eighth centuries</a>. </p>
<p>To this day, these schools help Sunni Muslims decide on issues such as worship, criminal law, gender and family, banking and finance, and even bioethical and environmental concerns. Today, <a href="http://www.brill.com/products/reference-work/yearbook-international-religious-demography-2017">Sunnis comprise about 80-90 percent of the global Muslim population.</a> </p>
<p>On the other hand, Shias relied on Imams as their spiritual leaders, whom they believed to be divinely appointed leaders from among the prophet’s family. Shia Muslims continue to maintain that the prophet’s family are the sole genuine leaders. In the absence of the leadership of direct descendants, <a href="https://books.google.de/books?redir_esc=y&hl=de&id=B0OL5Z8S-V0C&q=imamate#v=snippet&q=imamate&f=false">Shias appoint representatives to rule in their place</a> (often called ayatollahs). Shias are a minority of the global Muslim population, <a href="http://www.brill.com/products/reference-work/yearbook-international-religious-demography-2017">although they have strong communities</a> in Iraq, Pakistan, Albania, Yemen, Lebanon and Iran. There are also different <a href="https://books.google.de/books?id=5h2aCgAAQBAJ&printsec=frontcover&dq=denny+islam&hl=en&sa=X&ved=0ahUKEwjvoPmbwYbUAhWKjiwKHWK1CMQQ6AEIJjAA#v=onepage&q=Twelvers&f=false">sects within Shia Islam</a>. </p>
<h2>Differences masked during Hajj</h2>
<p>Other disputes that continue to exacerbate the divide include issues of theology, practice and geopolitics.</p>
<p>For example, when it comes to theology Sunnis and Shias draw from <a href="https://oneworld-publications.com/hadith-pb.html">different “Hadith” traditions</a>. Hadith are the reports of the words and deeds of the prophet and considered an authoritative source of revelation, second only to the Quran. They provide a biographical sketch of the prophet, context to Quranic verses, and are used by Muslims in the application of Islamic law to daily life. Shias favor those that come from the prophet’s family and closest associates, while Sunnis cast a broader net for Hadith that includes a wide array of the prophet’s companions. </p>
<p>Shias and Sunnis differ over prayer as well. All Sunni Muslims believe they are required to pray five times a day, but Shias can condense those into three. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170631/original/file-20170523-5782-1o7pzq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Hajj pilgrimage in Mecca, when both Shia and Sunni Muslims come together to pray.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/aljazeeraenglish/5175696974/in/photolist-8TmNoJ-pUn3E-TFF5iw-b28wFk-8TwBJr-8UeRy7-hhsunS-8SWbdP-4qY7mM-4GsGdi-8TCUEX-hhssws-8Tz1tf-9Wtc2d-8TvDnr-7m6S5M-8SZhyQ-h4zTbi-8TzJJj-7AUpkM-8VZVMs-hhu1NN-4j3Dty-5R5Xod-8UbLax-b28voc-4HBpax-5KXLR-8TyDvy-8SWcnr-8TkxKF-hhswGG-dZNDGX-kAeFMP-hhrD6A-8TvKzV-9Wtanw-8U9pyc-9WqMr8-9Wqzxa-8TvHvx-8TyFsS-8Tikfx-9Wtz7J-wdAZ-9WqAJ8-8Tz4sU-8SZgWf-9Wt689-8SZgF1">Al Jazeera English</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>During the Hajj – <a href="http://www.oxfordislamicstudies.com/article/opr/t125/e771">the pilgrimage to Mecca, held annually</a> and obligatory for all Muslims once in a lifetime – it may seem that these differences are masked, as both Sunnis and Shias gather in the holy city for rituals that reenact the holiest narratives of their faith. And yet, with Saudi authorities overseeing the Hajj, there have been tensions with Shia governments such as Iran over <a href="http://www.alterinter.org/spip.php?article4502">claims of discrimination.</a> </p>
<p>And when it comes to leadership, the Shia have a more hierarchical structure of political and religious authority invested in formally trained clergy whose religious authority is transnational. <a href="https://books.google.de/books?id=5h2aCgAAQBAJ&printsec=frontcover&dq=denny+islam&hl=en&sa=X&ved=0ahUKEwjvoPmbwYbUAhWKjiwKHWK1CMQQ6AEIJjAA#v=snippet&q=clergy&f=false">There is no such structure in Sunni Islam.</a></p>
<p>The greatest splits today, however, come down to politics. Although the majority of Sunni and Shia are able to live peacefully together, the current global political landscape has brought polarization and sectarianism to new levels. Shia-Sunni <a href="https://www.brookings.edu/blog/up-front/2013/06/08/sectarianism-and-the-politics-of-the-new-middle-east/">conflicts are raging in Syria, Iraq, Lebanon</a> and <a href="https://www.publishersweekly.com/978-0-19-062165-0">Pakistan</a> and the divide is growing deeper across the Muslim world. </p>
<p>This historical schism continues to permeate the daily lives of Muslims around the world.</p><img src="https://counter.theconversation.com/content/78216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ken Chitwood does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There have been several attacks on Shia mosques in several parts of the world. At its heart is the centuries’-old sectarian Shia-Sunni divide.Ken Chitwood, Ph.D. Candidate, Religion in the Americas, Global Islam, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/779302017-05-23T03:47:50Z2017-05-23T03:47:50ZWhat are software vulnerabilities, and why are there so many of them?<figure><img src="https://images.theconversation.com/files/169999/original/file-20170518-12263-iatux6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's software: There's always a way in.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/elite-hacker-entering-room-through-keyhole-420468124">BeeBright via shutterstock.com</a></span></figcaption></figure><p>The recent WannaCry ransomware attack spread like wildfire, taking advantage of flaws in the Windows operating system to take control of <a href="http://www.cbsnews.com/news/cyberattack-wannacry-ransomware-north-korea-hackers-lazarus-group/">hundreds of thousands of computers worldwide</a>. But what exactly does that mean?</p>
<p>It can be useful to think of hackers as burglars and malicious software as their burglary tools. Having researched cybercrime and technology use among criminal populations for more than a decade, I know that both types of miscreants want to find ways into secure places – computers and networks, and homes and businesses. They have a range of options for how to get in.</p>
<p>Some burglars may choose to simply smash in a window or door with a crowbar, while others may be stealthier and try to pick a lock or sneak in a door that was left open. Hackers operate in a similar fashion, though they have more potential points of entry than a burglar, who is typically dependent on windows or doors.</p>
<p>The weaknesses hackers exploit aren’t broken windowpanes or rusty hinges. Rather, they are flaws in software programs running on a computer. Programs are written by humans, and are inherently imperfect. Nobody writes software completely free of errors that create openings for potential attackers.</p>
<h2>What are these flaws, really?</h2>
<p>In simple terms, a vulnerability can be an error in the way that user management occurs in the system, an error in the code or a flaw in how it responds to certain requests. One common vulnerability allows an attack called a <a href="https://secure.php.net/manual/en/security.database.sql-injection.php">SQL injection</a>. It works on websites that query databases, such as to search for keywords. An attacker creates a query that itself contains code in a database programming language called SQL.</p>
<p>If a site is not properly protected, its search function will <a href="https://www.cisco.com/c/en/us/about/security-center/sql-injection.html">execute the SQL commands</a>, which can allow the attacker access to the database and potentially control of the website. </p>
<p>Similarly, many people use programs that are supported by the <a href="https://www.codecademy.com/learn/learn-java">Java programming language</a>, such as Adobe Flash Player and various Android applications. There are <a href="https://www.cvedetails.com/vulnerability-list/vendor_id-93/product_id-19117/Oracle-JRE.html">numerous vulnerabilities in the Java platform</a>, all of which can be exploited in different ways, but most commonly through getting individuals to <a href="https://doi.org/10.1145/2901739.2901773">download “plug-ins” or “codecs” to software</a>. These plug-ins actually contain malicious code that will take advantage of the vulnerability and compromise the machine. </p>
<h2>Flaws are everywhere</h2>
<p>Vulnerabilities exist in all types of software. <a href="https://arstechnica.com/security/2017/05/wcry-is-so-mean-microsoft-issues-patch-for-3-unsupported-windows-versions/">Several versions of the Microsoft Windows operating system</a> were open to the WannaCry attack. For instance, the popular open-source web browser Firefox has had <a href="https://www.cvedetails.com/product/3264/Mozilla-Firefox.html?vendor_id=452">more than 100 vulnerabilities identified in its code each year</a> since 2009. Fifteen different vulnerabilities have been identified in Microsoft Internet Explorer browser variants <a href="https://www.cvedetails.com/product/9900/Microsoft-Internet-Explorer.html?vendor_id=26">since the start of 2017</a>.</p>
<p>Software development is not a perfect process. Programmers often work on timelines set by management teams that attempt to set reasonable goals, <a href="https://blog.keen.io/how-should-deadlines-be-used-in-software-engineering-9eb23d513e8d">though it can be a challenge to meet those deadlines</a>. As a result, developers do their best to design secure products as they progress but may not be able to identify all flaws before an anticipated release date. Delays may be costly; many companies will release an initial version of a product and then, when they find problems (or get reports from users or researchers), fix them by releasing security updates, sometimes called patches because they cover the holes.</p>
<p>But software companies can’t support their products forever – to stay in business, they have to keep improving programs and selling copies of the updated versions. So after some amount of time goes by, they stop issuing patches for older programs. </p>
<p>Not every customer buys the latest software, though – so many users are still running old programs that might have <a href="https://arstechnica.com/security/2017/05/wcry-is-so-mean-microsoft-issues-patch-for-3-unsupported-windows-versions/">unpatched flaws</a>. That gives attackers a chance to find weaknesses in old software, even if newer versions don’t have the same flaws.</p>
<h2>Exploiting the weaknesses</h2>
<p>Once an attacker identifies a vulnerability, he can write a new computer program that uses that opportunity to get into a machine and take it over. In this respect, an exploit is similar to the way burglars use tools like crowbars, lock picks or other means of entry into a physical location. </p>
<p>They find a weak point in the system’s defenses, perhaps a network connection that hasn’t been properly secured. If attackers can manage to gain contact with a target computer, they can learn about what sort of system it is. That lets them identify particular approaches – accessing specific files or running certain programs – that can give them increasing control over the machine and its data. In recent years, attackers began targeting web browsers, which are allowed to connect to the internet and often to run small programs; they have many vulnerabilities that can be exploited. Those initial openings can give an attacker control of a target computer, which in turn can be used as a point of intrusion into a larger sensitive network.</p>
<p>Sometimes the vulnerabilities are discovered by the software developers themselves, or users or researchers who alert the company that a fix is needed. But other times, hackers or government spy agencies figure out how to break into systems and <a href="https://theconversation.com/should-spies-use-secret-software-vulnerabilities-77770">don’t tell the company</a>. These weaknesses are called “zero days,” because the developer has had no time to fix them. As a result, the software or hardware has been compromised until a patch or fix can be created and distributed to users. </p>
<p>The best way users can protect themselves is to <a href="https://theconversation.com/why-installing-software-updates-makes-us-wannacry-77667">regularly install software updates</a>, as soon as updates are available.</p><img src="https://counter.theconversation.com/content/77930/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Holt does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It can be useful to think of hackers as burglars and malicious software as their burglary tools. Both types of miscreants want to find ways into secure places and have many options for entry.Thomas Holt, Associate Professor of Criminal Justice, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/776062017-05-16T00:53:14Z2017-05-16T00:53:14ZThe FBI: With great power comes great scandal<p>Drama at the FBI is nothing new. Given its 109-year history, the FBI has seen many scandals and numerous directors come and go.</p>
<p>Its directors, in fact, have always been the face and driving force of the FBI. Most have retired or moved on to other work, four were forced to offer resignations, but only two, including most recently James Comey, have been fired outright.</p>
<p>While FBI directors always served at the pleasure of presidents, they differed in their closeness to the chief executive. Most notably, FBI Director J. Edgar Hoover (1924-1972) worked to satisfy the political interests of some presidents and secretly undermine others. Since his death in 1972 and revelations of abuses, the federal government has treated the FBI director as independent from the White House.</p>
<p>As a historian who has <a href="http://www.personal.psu.edu/dmc166/">long studied</a> the FBI and its work, I believe knowing the agency’s past is crucial to understanding the firing of FBI Director James Comey and what may come of it.</p>
<h2>The FBI’s origins</h2>
<p>When the FBI was founded in 1908 during the Progressive Era, federal law enforcement was in its infancy. The Justice Department was only 38 years old. It was established in 1870 during Reconstruction in an effort to protect the constitutional rights of African-Americans, significantly by <a href="http://law.jrank.org/pages/2612/South-Carolina-Ku-Klux-Klan-Trials-1871-72-Ku-Klux-Klan-Act.html">crippling the Ku Klux Klan</a>. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=782&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=782&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=782&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=982&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=982&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169377/original/file-20170515-7009-1a713gz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=982&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Stanley William Finch.</span>
<span class="attribution"><a class="source" href="https://www.fbi.gov/history/directors/stanley-w-finch">Federal Bureau of Investigation</a></span>
</figcaption>
</figure>
<p>As the U.S. experienced rapid and massive industrialization, a realization emerged: Only the federal government was powerful enough to reign in rampant corporate corruption and abuses. President Theodore Roosevelt established the Bureau of Investigation (“Federal” was added in 1935) by <a href="http://personal.psu.edu/dmc166/Bonaparte%201908.jpg">executive mandate</a>. Chief Examiner Stanley Finch became the first leader of the bureau. The title of “director” would not be adopted until later.</p>
<p>When the FBI was established, <a href="https://fas.org/irp/agency/doj/fbi/fbi_hist.htm">its purpose</a> was to help enforce federal anti-monopoly and interstate commerce laws by scouring corporate financial records for wrongdoing, while Justice Department attorneys prosecuted. This mission was at the behest of <a href="https://ehistory.osu.edu/exhibitions/1912/trusts/roosevel">President Roosevelt</a>, whose interests involved regulating abusive aspects of corporate capitalism. Over time, however, the FBI and its directors assumed increased responsibilities and became more independent. But balancing this authority and independence was sometimes a struggle, resulting in scandals.</p>
<h2>Expansion of authority</h2>
<p><a href="https://childhub.org/en/system/tdf/library/attachments/finch_1912_white_slave_tra.htm?file=1&type=node&id=16247">Finch</a> was obsessed with prostitution, calling it “evil” and writing widely about its threat. He avidly pursued it as head of the FBI.</p>
<p>His efforts were based on passage in 1910 of the White Slave Traffic Act, a law banning the transportation of women across state lines for “immoral purposes.” The bureau’s investigative responsibilities quickly expanded to include targeting prostitution rings. The law’s wording, however, was vague – resulting in FBI agents enforcing their ideas about morality and <a href="http://jessicapliley.com/writing.html">the proper roles of women and men</a>.</p>
<p>With passage of the Motor Vehicle Theft Act in 1919, FBI agents also began to target criminals driving stolen cars across state lines, like John Dillinger in the 1930s. The investigative realities of both laws made it necessary for agents to investigate crimes in the field, rather than examining financial records from behind a desk in Washington. The FBI established field offices across the country.</p>
<p>During World War I, the FBI’s responsibilities expanded again. This time it entered the field of domestic security. Fears of external influences abounded – immigrants, so-called “hyphenated Americans” like Italian-Americans and concerns over German espionage and sabotage. The <a href="https://www.fbi.gov/news/stories/the-bureaus-role-during-early-world-war-i-years">FBI independently enforced</a> new laws covering espionage, sedition, the draft and immigration.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=550&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=550&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169397/original/file-20170515-6990-prm0pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=550&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A. Bruce Bielaski, Director of Bureau of Investigation from April 30, 1912 to Feb. 10, 1919.</span>
<span class="attribution"><a class="source" href="https://multimedia.fbi.gov/original/2225">FBI/Library of Congress</a></span>
</figcaption>
</figure>
<p><a href="https://www.jstor.org/stable/41289314?seq=1#page_scan_tab_contents">A. Bruce Bielaski</a> was head of the bureau at the time. He was a former subordinate of Finch, a lawyer, son of a minister and member of the Justice Department baseball team. During his tenure, Congress investigated mass federal enforcement of the Selective Service Act. The <a href="https://books.google.com/books?id=VnQduXa4JdoC&pg=PA105&lpg=PA105&dq=slacker+raids+FBI&source=bl&ots=SCfVHs5YqP&sig=9QOmxHcYKQgb37qLIJJ8lMUisGU&hl=en&sa=X&ved=0ahUKEwjwoLu1qfLTAhWCZiYKHXcgD_gQ6AEINDAD#v=onepage&q&f=false">FBI rounded up</a> and illegally detained Americans until those who were detained could prove they had registered for the draft. Ultimately, Bielaski was forced to resign in February 1919 for his handling of the raids.</p>
<p>FBI improprieties did not end as the U.S. entered the 1920s. Under the leadership of William J. Burns, the first FBI head to use the title “director,” the country experienced what until Watergate was the granddaddy of American political scandals: the <a href="https://www.senate.gov/artandhistory/history/minute/Senate_Investigates_the_Teapot_Dome_Scandal.htm">Teapot Dome scandal</a>. </p>
<p>President Warren Harding’s financially strapped interior secretary, Albert Fall, had allowed oil companies to tap U.S. Navy emergency oil reserves in Teapot Dome, Wyoming, in return for kickbacks. Eventually Sen. Burton K. Wheeler and others discovered and began investigating the improprieties. </p>
<p>FBI Director Burns, at the request of Attorney General Harry Daugherty, tried to end the Senate probe. Burns was the owner of a private detective agency, and a man apt to believe investigative ends justified the means. He was not afraid to target powerful men. So, he dispatched agents to dig up dirt on Sen. Wheeler. Not finding any, he and Daugherty concocted baseless corruption charges against Wheeler that only backfired. The attorney general was fired and replaced with a reformer, who promptly forced the resignation of the corrupted <a href="https://www.fbi.gov/history/directors/william-j-burns">Bureau Director Burns</a> in 1924. The FBI was placed under the tutelage of J. Edgar Hoover. </p>
<p>Under Hoover, the FBI evolved from a relatively small investigative agency to a large, professional and influential law enforcement and national security body. It assumed arrest powers and focused on process and scientific detection techniques to target celebrated gangsters of the 1930s. Then, under President Franklin Roosevelt, it shifted to prioritize national security and intelligence investigations. </p>
<p>Over time, Hoover’s FBI also became notorious for its political intelligence gathering, <a href="https://kansaspress.ku.edu/978-0-7006-1825-5.html">obscenity investigations</a>, <a href="https://archives.fbi.gov/archives/news/stories/2005/july/j.-edgar-hoovers-official-confidential-files">secret files</a> and targeting of <a href="http://www.nytimes.com/1989/07/09/books/there-was-reason-not-to-trust-them.html">African-Americans</a>, <a href="https://kansaspress.ku.edu/978-0-7006-2119-4.html">gays</a>, war protesters and leftists. </p>
<h2>The modern FBI</h2>
<p>When the public became aware of these activities after Hoover’s death in 1972, the FBI worked to repair its damaged reputation. Congress further mandated that directors would serve a statutory 10-year term to avoid the abuses of an entrenched Hoover, who was director for 48 years. It would also help avoid FBI directors being subservient to partisan presidential interests.</p>
<p>Weeks before Watergate, Nixon sycophant <a href="http://www.nytimes.com/2005/07/07/politics/l-patrick-gray-iii-who-led-the-fbi-during-watergate-dies-at-88.html">L. Patrick Gray</a> stepped in to replace Hoover as acting director, and was nominated by Nixon to serve as permanent director. He soon withdrew his nomination, however, and resigned as acting director in April 1973, after admitting to destroying Watergate-related files.</p>
<p>Later came William Sessions, a former federal judge who took the job under President Ronald Reagan in 1987 and focused on white-collar crimes. Sessions, however, violated bureau procedures and federal law by using FBI resources for personal trips and home improvements. After an in-depth internal ethics investigation, he sternly resisted six months of White House demands for his resignation. President Bill Clinton personally telephoned Sessions and fired him in July 1993. This was the <a href="http://articles.latimes.com/1993-07-20/news/mn-15006_1_law-enforcement-agencies">first outright firing of a director</a>.</p>
<p>This brings us to James Comey, <a href="http://www.nytimes.com/2013/06/22/us/politics/obama-says-comey-will-strike-balance-on-security-and-privacy-at-fbi.html">famous for his Boy Scout’s reputation and independence streak</a>, and now only the second FBI director to be fired outright. There are shifting accounts over why he was fired, focusing either on his handling of Hillary Clinton’s emails or the Trump-Russia investigation. Unlike the case of Sessions, where an internal probe was first concluded, the inspector general’s examination of Comey’s actions in the 2016 election have not yet ended and <a href="https://theconversation.com/comeys-firing-may-end-other-investigations-into-2016-election-77532">its status is unclear</a>.</p>
<p>Also unlike Sessions, where he was pressured for six months to quit, Comey’s firing was sudden and indirect – he heard about it from news reports while visiting an FBI field office – with a <a href="https://www.nytimes.com/interactive/2017/05/09/us/politics/document-White-House-Fires-James-Comey.html">paper trail</a> of recommendations about it dated only to the actual day of the firing. How this all will unfold remains unclear, but it is a dramatic moment in a long history of FBI directors and their exits fitted to their times.</p><img src="https://counter.theconversation.com/content/77606/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Douglas M. Charles does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An FBI historian tells stories from the agency’s ups and downs over 109 years and four dismissed directors.Douglas M. Charles, Associate Professor of History, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755912017-04-20T23:18:36Z2017-04-20T23:18:36ZWhy are we dragging our feet when more automation in health care will save lives?<figure><img src="https://images.theconversation.com/files/165698/original/image-20170418-32726-ro3ifj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From closed-loop ventilators to smarter vital sign monitors, automation has untapped potential to improve medical outcomes.</span> <span class="attribution"><span class="source">From www.shutterstock.com</span></span></figcaption></figure><p>As a neonatologist, I worry about patients with <a href="https://pulmonaryhypertensionnews.com/pulmonary-hypertension-newborns/">pulmonary hypertension</a>. This unforgiving disease, sometimes seen after premature birth, can end with sudden death from constricting blood vessels in the lungs. One minute a baby in the neonatal ICU may be sleeping comfortably; moments later, doctors and nurses are giving chest compressions and rescue medications.</p>
<p>A pulmonary hypertension crisis, as these frightening episodes are called, starts with a drop in the blood oxygen level. That drop triggers a monitor to beep. It’s up to the nurse to hear the sound, come to the bedside and take action.</p>
<p>The first and most effective step in stopping a pulmonary hypertension crisis is simple: Give oxygen. But a nurse caring for another patient might be delayed for 30 seconds, and the loss of that time can lead to brain injury or death.</p>
<p>In an age of <a href="https://www.wired.com/2016/12/google-self-driving-car-waymo/">self-driving cars</a> and 400-ton <a href="http://www.usatoday.com/story/travel/columnist/cox/2014/02/09/autoland-low-visibility-landings/5283931/">airplanes that can land themselves</a> in blinding fog, it makes no sense that hospitalized patients are surrounded by lifesaving machinery that can be activated only by a person pressing a button or turning a knob. </p>
<p>Modern transportation augments human judgment and reaction times with a computer’s superior ability to continuously respond to dozens of fluctuating variables. Yet in medicine, safety remains stubbornly reliant on human intervention.</p>
<h2>FDA regulation impedes innovation</h2>
<p>My patients with pulmonary hypertension are often attached to a respirator with adjustable oxygen settings. The respirator sits inches below the monitor that indicates how much oxygen is in the blood. But the two machines can’t communicate with each other. If they could, it would be possible to increase the flow of oxygen automatically the moment a crisis is detected.</p>
<p>In 2009, engineers developed just this kind of <a href="http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2013-1834">closed-loop respirator</a> and introduced it in several hospitals as part of a feasibility study. It increased the time premature babies spent at a safe oxygen level by more than two hours per day. But no biotechnology company has marketed the idea.</p>
<p>There are other examples of automated systems with unrealized potential to save lives, and not just in the neonatal ICU. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26616400">Software that scans an ECG for subtle heartbeat variability</a> can identify patterns – undetectable to the human eye – that indicate an elevated risk of heart attack. <a href="http://cdn.laerdal.com/downloads/f2644/ReviewCPRdevices06_09.pdf">Hospital beds that play audible feedback during an emergency</a> promote more effective CPR. Yet patients are not benefiting because neither of these tools has been commercialized.</p>
<p>Why haven’t these innovations attracted the industry backing necessary to make them widely available?</p>
<p>One reason is that <a href="https://its.utmb.edu/documents/FDA-Medical-Device-Regulatory-Process-Timeline.pdf">the process of getting FDA approval for new devices</a> – particularly those deemed “life-sustaining” – is often <a href="http://progressivefix.com/wp-content/uploads/2011/06/06.2011-Mandel_How-the-FDA-Impedes-Innovation.pdf">even more complicated</a> and expensive than getting approval for drugs. In the Journal of Public Economics, Harvard Business School professor Ariel Dora Stern recently described how <a href="http://www.aami.org/productspublications/articledetail.aspx?ItemNumber=3807">FDA hurdles discourage companies from investing in innovation</a>.</p>
<p>Often, the more profitable strategy is to wait for someone else to spend the time and money required to get approval for a new device, and then enter the market later with something similar that will face less scrutiny. Dr. Stern estimates that regulatory obstacles add an average of US$6.7 million to the cost of introducing a new medical device. For a company developing an ICU monitor, for instance, that will ultimately sell for less than <a href="http://www.zdnet.com/article/how-philips-maintains-monitor-price-points/">$35,000 per unit</a>, this up-front commitment can be prohibitive.</p>
<p>A consequence is that small biotechnology firms (with annual revenue less than $500 million) rarely gamble on getting new inventions approved. Dr. Stern’s paper notes that less than 17 percent of novel device applications to the FDA come from small companies. This is different from new drug applications, the majority of which originate at smaller firms.</p>
<p>What’s behind this discrepancy? Research has shown that while companies pay a steep price for pioneering new medical devices, the first firm to market a new type of drug often gets <a href="https://academic.oup.com/jleo/article-lookup/doi/10.1093/jleo/ewp002">favorable treatment from the FDA</a>. This raises the incentive for pharmaceutical startups to pursue innovation. In contrast, when it comes to medical devices, the current system discourages all but the biggest players from entering the arena.</p>
<p>And even when a new device has been approved, there is no strong impetus for hospitals and clinics to buy in. Even if they can afford upgrades, medical sites are free to use older equipment, with fewer safety mechanisms, long after improved versions become available.</p>
<h2>A chance for Washington to improve health care</h2>
<p>In contrast, a variety of government initiatives prod transportation companies to modernize. For example, the Federal Aviation Administration <a href="https://www.faa.gov/nextgen/equipadsb/rebate/">offers rebates</a> to aircraft owners to offset the cost of advanced navigation technology that prevents midair collisions. The Federal Rail Administration is overseeing mandatory, nationwide installation of <a href="https://www.fra.dot.gov/ptc">a GPS-based system to slow down speeding trains automatically</a>.</p>
<p>There is an opportunity here – beyond the messy Obamacare debate – for the White House and congressional Republicans to stimulate economic growth in the biomedical sector while improving patient safety. Streamlining the approval process for new devices and offering financial incentives for early adopters would not threaten anti-regulatory groups, and would allow the new administration to claim progress in health care.</p>
<p>President Trump has expressed interest in <a href="https://theconversation.com/faster-access-to-new-drugs-doesnt-always-mean-better-treatment-74369">expediting pharmaceutical approvals</a>, something FDA commissioner Scott Gottlieb <a href="https://www.forbes.com/sites/scottgottlieb/2016/10/24/epipen-drug-pricing-challenge/4/#15f88b7146ad">also supports</a>. But most drugs help only a small segment of the population.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=642&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=642&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=642&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=806&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=806&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=806&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dr. Scott Gottlieb, nominee for FDA commissioner.</span>
<span class="attribution"><span class="source">J. Scott Applewhite/AP</span></span>
</figcaption>
</figure>
<p>The president and Dr. Gottlieb should commit to advancing commonsense technology that makes health care better for all.</p>
<p>I’m not suggesting that machines should take over for health professionals. As in the manufacturing industry, the medical field is experiencing mounting anxiety about job displacement. There are many perceived threats, from <a href="https://www.technologyreview.com/s/600706/ibms-automated-radiologist-can-read-images-and-medical-records/">artificial intelligence X-ray interpretation</a> to <a href="http://www.thedailybeast.com/articles/2016/09/24/robot-nurses-will-make-shortages-obsolete.html">robot nurses</a>.</p>
<p>Those things might become commonplace, but they will never supplant the human relationships and insights at the core of medical practice. Neither will the kinds of safety innovations I’m recommending. With help from our leaders, physicians can take better care of patients by bringing more automation into our wards and offices.</p><img src="https://counter.theconversation.com/content/75591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Hooven owns shares of Atricure, a biotechnology company.</span></em></p>In planes, trains and cars, we increasingly entrust our lives to automated safety systems. It’s time for medical technology to catch up.Thomas Hooven, Neonatologist, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/655422016-10-07T20:29:00Z2016-10-07T20:29:00ZFighting another war: How many military personnel and veterans will have PTSD in 2025?<figure><img src="https://images.theconversation.com/files/140940/original/image-20161007-21421-p8ivly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need better estimates of PTSD to find the best policies to treat it. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/marine_corps/4949341330/in/photolist-8xmEKd">Marines via Flickr</a></span></figcaption></figure><p>Post-traumatic stress disorder is a serious public health challenge. It is estimated that about <a href="http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp">eight million</a> people in the U.S. (2.5 percent of the total population) suffer from it. This rate jumps to about <a href="http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp">11 to 20 percent</a> among Iraq and Afghanistan veterans who suffer from diagnosed or undiagnosed PTSD.</p>
<p>Affected individuals might lose their career or family or even commit <a href="https://www.ncbi.nlm.nih.gov/pubmed/15985839">suicide</a> due to the consequences of PTSD. The effects go beyond the individuals coping with it, extending to their family, friends, colleagues and communities. </p>
<p>Both military personnel and veterans can be affected by PTSD. However, the exact prevalence of PTSD among these two groups is unknown. This not only makes it hard to know how many people actually have PTSD but also makes it even harder to project how many will in the future. And if we don’t know how many people actually have PTSD, it can be hard to find out what policies work best to mitigate it.</p>
<p>To address these concerns, my colleagues Navid Ghaffarzadegan and Alireza Ebrahimvandi at Virginia Tech and I decided to take a <a href="https://en.wikipedia.org/wiki/Systems_science">systems science</a> approach which lets us study how parts of a large system, such as the Department of Veterans Affairs and the Department of Defense, interconnect. </p>
<p>We developed a simulation model to project the prevalence of PTSD by 2025 among military personnel and veterans and to find out what policies actually reduce the burden. Our study presenting the model was recently <a href="http://dx.doi.org/10.1371/journal.pone.0161405">published</a> in PLOS ONE.</p>
<h2>The challenge of estimating PTSD prevalence</h2>
<p>Because screening of PTSD is based on self-reported surveys, estimating its true prevalence among veterans and current military personnel is hard to do. Answers to surveys can suffer from patients’ errors. </p>
<p>But more importantly, some PTSD patients may intentionally underplay their mental health condition to avoid being labeled as mentally ill. In a few cases, patients may <a href="https://books.google.com/books?id=bpO-B5B_LsoC&pg=PT141">exaggerate</a> their problems for motives of secondary gain, such as disability compensation. </p>
<p>Our task was to put all of this information together to gain a true sense of the future prevalence of PTSD among military personnel and veterans.</p>
<h2>PTSD is a multi-organizational challenge</h2>
<p>Another challenge is that we are talking about two different populations: people currently in the military, and veterans. </p>
<p>The VA and the military are two systems within a larger system. They establish different policies, which may result in improvements in their own sectors, but are not so effective in the larger system. For instance, policies implemented in the early stages of a person’s military career, when combat readiness is a major concern, can cause serious consequences years after separation from the military. </p>
<p>In systems science, this is called “shifting the burden.” Unless the military and the VA come together to develop integrated policies, the big picture of the system will be missed by disjointed policies implemented in each organization. </p>
<p>Since PTSD is a multi-organizational challenge, estimates should take both populations into account simultaneously, which is what we did in our model.</p>
<h2>Simulating the burden of PTSD</h2>
<p>Our model includes both military personnel and veterans affected by PTSD in a “system of systems.” It uses historical data on PTSD prevalence among military personnel and veterans from the DOD, the Institute of Medicine, the VA and other sources, from 2000 to 2014. This let us validate our model and generate a more exact estimate of PTSD prevalence. </p>
<p>Our approach also allows us to ask “what-if” questions about the consequences of current policies – such as what if we focus solely on improving screening or improving screening and treatment.</p>
<p>Then we used the model to forecast PTSD prevalence over the next decade under several scenarios. These scenarios are based on common “what-ifs,” including different levels of U.S. involvement in future wars and improvements in prevention, screening and treatment. </p>
<h2>What happens if we fight another war?</h2>
<p>In an optimistic scenario where 1 percent of all military personnel are deployed to combat zones (which reflects deployment in 2014) that no war happens in the next decade, we estimate that 7 percent of military personnel and 10 percent of veterans will have PTSD by 2025.</p>
<p>But that could increase to 20 percent in the military and more than 11 percent among veterans in 2025 if the U.S. gets involved in a war requiring 5 percent deployment of all military personnel on battlefield. For perspective, from 2001 to 2014, on average, 6.6 percent were deployed annually. Larger wars with higher deployment rates will noticeably increase the prevalence of PTSD. </p>
<p>We also estimated the delay in mitigating the effects of a hypothetical war. Let’s assume that the U.S. involves in a five-year war with 10 percent troop deployment (similar to the maximum deployment in Iraq in 2008).</p>
<p>After the end of this hypothetical war, it will take about 40 years for PTSD prevalence to go back to its initial rate. This estimation shows how long the effects of war can endure.</p>
<h2>What policies work best?</h2>
<p>We also tried to get a sense of what policies work best at mitigating the problem of PTSD. Using the model, we examined the long-term effects of policies within the individual components of the system, the VA and the DOD, as well as across the entire system.</p>
<p>We found that, before and during wars, prevention interventions (focusing on resiliency-related training) are the most effective policy to decrease the prevalence of PTSD. Improving resiliency can work as a “vaccine” or early treatment before the onset of the cascading effects of PTSD. </p>
<p>However, social barriers such as the stigma of PTSD are still in place, affecting <a href="https://dspace.mit.edu/bitstream/handle/1721.1/102540/Ghaffarzadegan%26Larson2015USAMDJ_PTSD%20Vicious%20CyclesPublished.pdf?sequence=1">willingness</a> to receive early treatment.</p>
<p>Overall, our results show that in a post-war period there is no easy solution for overcoming the problem of PTSD, and the current screening and treatment policies used by the VA and the DOD must be revolutionized to have any noticeable effect. </p>
<p>The VA and the DOD should work together and try to offer timely service to patients. However, we showed that they cannot do much to decrease health care costs. These are the consequences of wars. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=608&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=608&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=608&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=764&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=764&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140796/original/image-20161006-32691-14wamd8.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=764&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Health care costs in the military and the VA, and PTSD prevalence in the total system in 2025. Scenario one represents minimum deployment, 1 percent of personnel to intense/combat zones, the status quo in 2014. Scenarios two and three represent 2 percent and 5 percent deployment. For each scenario, the results of improvements in screening, treatment or prevention, or any of their combinations, are shown.</span>
<span class="attribution"><a class="source" href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161405">N. Ghaffarzadegan et al (2016) A Dynamic Model of Post-Traumatic Stress Disorder for Military Personnel and Veterans.</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>We hope that the findings of this study will help the military, the VA, and other government entities identify more effective strategies. The results also show the importance of effective interaction among these large entities. We have provided the model <a href="https://forio.com/simulate/jalali/ptsd-simulation/simulation">online</a>, in an interactive interface and easy-to-interpret fashion, for the use of the public and policymakers.</p><img src="https://counter.theconversation.com/content/65542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mohammad S. Jalali does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We need to know how many people have PTSD to figure out what policies can reduce the burden.Mohammad S. Jalali, Research Faculty, MIT Sloan School of ManagementLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/646452016-09-02T01:32:24Z2016-09-02T01:32:24ZEarly stage breast cancer: How to know whether to forgo chemo<figure><img src="https://images.theconversation.com/files/136353/original/image-20160901-1023-1ho483m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Woman receiving chemotherapy.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-171516044/stock-photo-chemotherapy.html?src=zo7sMOyCUrlIlC0YJ1iIzA-1-10">From www.shutterstock.com</a></span></figcaption></figure><p>There has been substantial publicity about the <a href="http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=867#.V8cyUDbSfq0">MINDACT trial</a>, which could lead to changes in breast cancer treatment. The study’s results suggest that women with a certain genetic profile would have a good chance of survival and cure regardless of chemotherapy. </p>
<p>While the results are encouraging, breast cancer treatment decisions are complex, and this study does not necessarily provide a clear yes or no answer about the need for chemotherapy. </p>
<p>As oncologists, we see this latest scientific development as yet another powerful tool in assessing a patient’s risk of developing cancer recurrence. </p>
<p>However, the study results cannot be used as a sole tool to help guide treatment decision making. It does not tell you that if a patient has a genetic profile associated with high risk of recurrence, taking chemotherapy would change that risk. </p>
<p>In essence, this trial is one more tool to inform patients and physicians about a tumor’s biologic behavior (more or less aggressive, more or less chance of development of a cancer recurrence). But the take-home message is that these results still do not help physicians and patients decide if chemotherapy can be skipped or not. </p>
<h2>A treatment mainstay</h2>
<p>For years, surgery was usually the first step to remove a breast cancer tumor from the body. Both surgery and radiation (needed in certain cases) are helpful in promoting “local control” of the breast cancer. Treatments such as chemotherapy and/or hormone-blocker pills are considered as additional or <a href="http://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=45587">adjuvant</a> treatments, to help “sterilize” the rest of the body (“systemic control”) from potential microscopic cancer cells that can break off from the original tumor in the breast, and ultimately may be responsible for the so-called distant recurrence of the breast cancer. </p>
<p>The decision of whether a breast cancer patient will receive chemotherapy and/or hormone-blockers is based on many factors, including tumor size, grade, lymph node status, and presence or absence of hormone receptors or HER2 receptors. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/136354/original/image-20160901-1036-1wh13xt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Woman with hair loss after chemo.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-174191054/stock-photo-cancer-woman.html?src=zo7sMOyCUrlIlC0YJ1iIzA-2-11">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>In years past, chemotherapy was given to most women. It often brings unpleasant side effects, including nausea, hair loss and fatigue. Some of the toxic drugs used in chemotherapy can sometimes cause health issues years down the road, such as thinking or memory problems called <a href="http://www.mayoclinic.org/diseases-conditions/chemo-brain/home/ovc-20170224">chemo brain</a>. </p>
<p>In addition, chemotherapy requires a great deal of time. It is also <a href="http://www.ncbi.nlm.nih.gov/pubmed/19354340">expensive</a>, often costing tens of thousands of dollars, US.
The decision of whether to have chemotherapy or not is, thus, a very important choice for hundreds of thousands of women receiving treatment for breast cancer. It is understandable that many women prefer not to have chemotherapy.</p>
<p>The good news is that many women with early stage disease are now potentially cured, sometimes without chemotherapy given after surgery. </p>
<h2>Better understanding of a complex disease</h2>
<p>Breast cancer is the <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics">most common cancer diagnosis</a> and the second leading cause of cancer-related deaths in American women. Only lung cancer kills more women.</p>
<p>Not all breast cancers are alike. In fact, we are finding that many are much more aggressive than others. Many respond well to new therapies. </p>
<p>In a new era of personalized medicine, we, as oncologists who specialize in breast cancer, have much more information than ever to guide us in helping our patients. </p>
<p>Research has found that more than 75 percent cases of breast cancer express what we call hormone-receptors, which are proteins in the cancer cell that are “fed” by the hormone estrogen. This “fuel”, in turn, causes the cells to grow and divide. These cancers are called estrogen-receptor positive, or ER+. Treatment of early stage ER+ breast cancer consists of surgery, sometimes radiation, and hormone-blocker (endocrine) therapy with or without chemotherapy. </p>
<p>After a woman’s tumor is examined in a biopsy, some of the recently developed profiling tools can be used to help assess risk of recurrence and death in a more precise way.</p>
<p>First, there is <a href="https://www.adjuvantonline.com">Adjuvant! Online</a>. This software provides an estimation of chemotherapy effectiveness when added to endocrine therapy, based on clinical-pathologic features, or what we see in a patient upon exam, or what we learn through laboratory tests.</p>
<p>Second, there is <a href="http://www.oncotypedx.com">Oncotype DX</a>, a 21-gene test, that actually has the ability to predict chemotherapy benefit and the likelihood of distant breast cancer recurrence, or metastasis.</p>
<p>More recently, a third tool called <a href="http://www.agendia.com/healthcare-professionals/breast-cancer/mammaprint/">MammaPrint</a> was developed. This 70-gene signature examines 70 genes involved in breast cancer growth and survival, and was the one tested in the MINDACT trial. Unlike Oncotype DX, it only provides risk assessment (low risk or high risk) for distant recurrence, or metastasis, but it does not predict chemotherapy benefit. </p>
<p>The purpose of the <a href="http://www.eortc.org/news/mindact-mammaprint-genetic-test-can-reduce-use-of-post-surgery-chemotherapy-among-early-stage-breast-cancer-patients/">MINDACT</a> (Microarray in Node-Negative and 1 to 3 Positive Lymph Node Disease May Avoid Chemotherapy) trial, an international, prospective, randomized phase 3 study, was to determine the clinical utility of the addition of the 70-gene signature (MammaPrint) to standard criteria in selecting patients for chemotherapy. </p>
<p>The analysis focused on patients with discordant risk results. These included those with cancers that showed high clinical risk but low genomic risk. High clinical risk would include a woman who had a larger tumor size and more lymph node involvement. Low genomic risk refers to those cancers lacking the genes that signify aggressive growth.</p>
<p>The women were randomly selected, based on high or low clinical risk, or on high or low genomic risk. The women that had both low clinical and genomic risk did not receive chemotherapy and were not evaluated in the trial. The women with both high clinical and genomic risk all received chemotherapy in addition to endocrine therapy, and were also not evaluated in the trial. The women with discordant risk (i.e. high genomic risk but low clinical risk, or low genomic risk and high clinical risk) were all treated with endocrine therapy, but were randomized to either receive chemotherapy or to not receive chemotherapy. </p>
<p>In the group of women with high clinical risk but low genomic risk who were treated with chemotherapy, there was only a <a href="http://www.eortc.org/news/mindact-mammaprint-genetic-test-can-reduce-use-of-post-surgery-chemotherapy-among-early-stage-breast-cancer-patients/">1.5 percent increase</a> in the five-year survival rate, without the cancer spreading to another organ in the body, the authors reported. (95.9 percent in the chemotherapy group vs 94.4 percent in the no chemotherapy group). Since the five-year survival is very similar in both groups, it is still unclear who are the women that actually can truly be spared of chemotherapy. Similar results were seen in the group of women with low clinical risk but high genomic risk (i.e. the five-year survival rate was very similar between the patients randomized to chemotherapy or not).</p>
<h2>Bringing all the information together</h2>
<p>So what does this mean for our patients in the clinic? Let us consider two hypothetical clinical scenarios.</p>
<p>Patient 1 is a 55-year-old woman with a 1.5 centimeter tumor that is ER+, low-grade, low <a href="http://www.breastcancer.org/symptoms/diagnosis/rate_grade">proliferative rate</a> with 0 of 3 sentinel lymph nodes, or <a href="http://www.cancer.gov/about-cancer/diagnosis-staging/staging/s%E2%80%A6">nodes </a>to which the tumor is most likely to have spread. Proliferative rate refers to the rate of growth of cells within the tumor; <a href="http://www.breastcancer.org/symptoms/diagnosis/rate_grade">less than six percent is low</a>, and greater than 10 percent is high.</p>
<p>Based on these clinical-pathologic features of her tumor, she is considered to have low clinical risk. According to results from the MINDACT trial, her clinical risk would trump her genomic risk, therefore, getting a MammaPrint test would be a waste of time and money. </p>
<p>Patient 2 is a 55-year-old woman with a 3.0 cm tumor that is ER+, high-grade, intermediate proliferative rate, with 2 to 5 positive sentinel lymph nodes. The patient is adamant about not receiving chemotherapy. Based on the clinical-pathologic features of her tumor, she is considered to have high clinical risk, and chemotherapy followed by endocrine therapy would be the standard of care recommendation. </p>
<p>If her MammaPrint test returns as low genomic risk, we could counsel the patient about her risk of distant metastasis without chemotherapy and breathe a sigh of relief if she had low genomic risk. She would certainly benefit from <a href="http://www.hopkinsmedicine.org/breast_center/treatments_services/survivor_care/endocrine_therapy/">endocrine therapy</a>, a daily, oral medication, for five to 10 years to reduce her risk of <a href="http://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer/art-20044575">distant recurrence</a>, or cancer that has spread, or metastasized.</p>
<p>It is not clear, however, whether she would be in the 1.5 percent of patients who might have benefited from chemotherapy but did not receive it, or in the group of patients who were spared the toxicity of chemotherapy based on the MINDACT trial.</p>
<p>These cases illustrate the complexity of clinical decision making in an era when we have a growing amount of data about the biology of each patient’s cancer. The MammaPrint test as used in the MINDACT trial suggests but does not predict a patient’s benefit from chemotherapy. It is merely a prognostic tool that tells us that the biology of the tumor matters. We already knew this. </p>
<p>For this reason, we believe the MammaPrint test is another tool which may help patients understand their risk of recurrence better. It is important that patients continue to have active discussions with their physicians about treatment options based on these gene panel tests in an effort to achieve personalized care.</p><img src="https://counter.theconversation.com/content/64645/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New tools help doctors and breast cancer patients decide whether chemotherapy is needed. A recent study suggested that many can forgo chemo. But the decision is complicated. Here’s why.Valerie Malyvanh Jansen, Clinical Instructor, Vanderbilt UniversityIngrid Mayer, Associate professor of medicine, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/636272016-08-10T22:20:49Z2016-08-10T22:20:49ZWhat can a 1.7-million-year-old hominid fossil teach us about cancer?<figure><img src="https://images.theconversation.com/files/133391/original/image-20160808-18010-8sjngf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Volume rendered image of the external morphology of the foot bone shows the extent of expansion of the primary bone cancer beyond the surface of the bone.</span> <span class="attribution"><a class="source" href="http://www.eurekalert.org/multimedia/pub/120746.php?from=334527">Patrick Randolph-Quinney (UCLAN)</a></span></figcaption></figure><p>In late July, <a href="http://doi.org/10.17159/sajs.2016/20150471">an international team of researchers</a> announced that they had identified evidence of cancer in the fossilized remains of a biological relative of human beings who lived about 1.7 million years ago.</p>
<p>It is rare to find fossils from the hominid family tree. Finding one with such well-preserved evidence of a tumor is rarer still.</p>
<p>It seems that cancer has been with us for quite some time, and this finding highlights one of the most fascinating questions about it: why cancer exists in the first place.</p>
<p>Cancer is a deadly disease and would have been particularly lethal before the recent development of effective treatments. So why didn’t it – or our susceptibility to it – die out long ago? </p>
<p>To put the question somewhat differently, why should organisms, including human beings, carry within our DNA the instruments of our own destruction – tumor suppressor genes and oncogenes just waiting for environmental insults before they kill their carriers? Shouldn’t organisms with such genes be selected against in the evolutionary competition to survive and reproduce?</p>
<h2>An ancient osteosarcoma</h2>
<p>Before addressing that question, let’s go back to the 1.7-million-year-old tumor.</p>
<p>The researchers found the cancer in a metatarsal, one of the long bones of the foot found just behind the toes. The researchers examined the specimen with high-resolution x-rays, revealing the lesion in greater detail and producing a three-dimensional image, which revealed an “irregular spongy woven bone texture with a cauliflower-like external appearance.” In other words, the cells of the tumor had grown in a disorganized fashion and were ballooning out from the shaft of the bone – features of a malignancy. They concluded that it was a bone cancer, probably an osteosarcoma. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133393/original/image-20160808-18010-hcwokh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A different view of the tumor in the metatarsal bone.</span>
<span class="attribution"><a class="source" href="http://www.eurekalert.org/multimedia/pub/120747.php?from=334527">Edward Odes/University of the Witwatersrand</a></span>
</figcaption>
</figure>
<p>As a radiologist working in a children’s hospital, I regularly see x-ray, CT and MRI scans of patients with osteosarcomas. They account for a fraction of all primary bone cancers, and are most often diagnosed in adolescence and young adulthood. One unusual feature of the South African report is the location of the tumor – the leg and arm are much more common sites than the foot.</p>
<p>Osteosarcomas arise from abnormal bone-producing cells. In fact, the name osteosarcoma comes from Greek roots meaning “bone” and “fleshy growth.” </p>
<p>Osteosarcomas aren’t just found in humans. They represent the most <a href="http://wearethecure.org/learn-more-about-canince-cancer/canine-cancer-library/osteosarcoma/">common bone malignancy found in dogs</a> <a href="http://www.vcahospitals.com/main/pet-health-information/article/animal-health/osteosarcoma-in-cats/316">and cats</a>. In fact, osteosarcomas are <a href="http://dx.doi.org/10.1093/ilar/ilu009">more common in dogs than people</a>, <a href="http://www.vet.upenn.edu/docs/default-source/ryan/oncology-handouts/bone-tumors-in-dogs_ek-ks.pdf?sfvrsn=4">especially in large species</a> such as <a href="http://rrcus.org/rhodesianridgebackhealth/Documents-PDFs/Osteosarcoma.pdf">greyhounds and great danes</a>. </p>
<p>Cancer has been around for much longer than 1.7 million years. In Indianapolis, our <a href="https://www.childrensmuseum.org/blog/meet-the-gorgosaur-v2">Children’s Museum</a> features the fossilized skull of a Gorgosaurus, a relative of Tyrannosaurus rex which lived during the Cretaceous period about 70 million years ago. It shows clear evidence of a golf-ball-sized mass inside the skull cavity. </p>
<h2>Cancer isn’t a single disease</h2>
<p>One challenge in attempting to understand the causes of cancer is the fact that cancer is not a single disease. </p>
<p>There are many different types of cancer, which can be categorized according to the organ in which they originate – lung cancer, colon cancer, breast cancer and so on. Better yet, they can be categorized by the type of tissue they represent. For example, carcinomas arise from epithelial or lining cells, sarcomas from connective cells, and leukemias from blood-forming cells.</p>
<p>What we call cancer really represents a family of disorders, all of which can be lumped together because of a common feature – disrupted regulation of cell growth.</p>
<p>For example, genes that normally suppress cell growth may be damaged, leading to uncontrolled proliferation. An indication that all cancers are not the same is the fact that they have very different prognoses and treatments.</p>
<p>Today evidence suggests that many cancers can be traced to environmental exposures, such as tobacco, dietary carcinogens, infections, and air and water pollution. It seems unlikely that tobacco or air pollution could have caused cancer millions of years ago, but it’s possible that some dietary and infectious agents may have been more common in the remote past. </p>
<h2>Chromosomes and oxygen</h2>
<p>One of the first explanations for how cancer could result from chromosomal damage was provided by a medical school professor of mine at the University of Chicago, <a href="https://news.uchicago.edu/article/2013/12/17/janet-rowley-cancer-genetics-pioneer-1925-2013">Janet Rowley, M.D</a>. In the 1970s, Dr. Rowley showed that in many patients with a type of leukemia, CML, <a href="http://www.nature.com/nature/journal/v243/n5405/abs/243290a0.html">portions of chromosomes 9 and 22 had been exchanged</a>, proving that changes in DNA could lead to cancer.</p>
<p>Part of the blame for cancer may be placed on a rather unexpected culprit, a molecule without which human life would be utterly impossible – oxygen. Oxygen is necessary for our cells to convert food to energy. This is one of the reasons that the human body is equipped with over 60,000 miles of blood vessels, which enable red blood cells to carry oxygen to each of our 75 trillion cells.</p>
<p>But oxygen is not an entirely benign molecule. In fact, it is highly reactive and even toxic in high concentrations. And early in Earth’s history, oxygen levels began to rise dramatically, as plants capable of photosynthesis – a process that produces oxygen – proliferated. More oxygen permitted the development of multicellular organisms capable of transporting oxygen to all of their cells. </p>
<p>Oxygen becomes problematic when <a href="http://dx.doi.org/10.3109/10715761003667554">superreactive forms</a> of it are formed. For example, when ionizing radiation strikes a cell, it can form superoxides that react avidly with nearby molecules. When one of the nearby molecules is DNA, damage to genes occurs, producing mutations that can be carried from one generation of cells to another. In some cases, a transformation to cancer may result. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133385/original/image-20160808-18053-slt6xy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Human malignant osteosarcoma (bone cancer) cells from a leg mass.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Osteosarcoma_(bone_cancer).jpg">National Cancer Institute via Wikimedia Commons</a></span>
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<h2>Will cancer always be with us?</h2>
<p>Another reason that cancer has persisted is the fact that it tends to be a disease of older organisms. Only <a href="http://www.cancer.org/cancer/cancerinchildren/detailedguide/cancer-in-children-key-statistics">1 percent of the cancers</a> diagnosed each year in the U.S. occur in children. So for most of our biological history, when life expectancy was shorter, hominids reproduced and died of other causes long before cancer had a chance to develop.</p>
<p>In advanced countries today, mortality rates due to other diseases, such as infections, <a href="http://dx.doi.org/10.1001/jama.2015.12319">heart disease and stroke</a>, have fallen so far that many more people are living to advanced ages, by which point the series of mutations necessary to induce cancer have had sufficient time to occur. In effect, rising cancer rates are in part a sign of general good health and longevity.</p>
<p>Can we make cancer disappear? The fundamental problem with cancer cells is that they do not know when to stop growing and die, and as a result, they keep proliferating in an uncontrolled fashion. While this is highly injurious to the organism, the existence of genes that promote cell growth is obviously crucial for organisms to grow and survive in the first place.</p>
<p>Consider an automobile. Just two weeks ago, the brakes on my car failed, a dangerous situation. We might wish that cars were built so that the brakes could never fail, but the only way to eliminate the possibility of brake failure would be to do away with the brake system altogether, a far more hazardous proposition.</p>
<p>The same thing can be said about cancer. We might wish that we were built without genes that can contribute to the development of cancer, but normal growth and development – and yes, even death – might not be possible without them. When it comes to life, we must take the bad as well as the good, though this is not to say that we cannot make strides in preventing and curing cancer.</p>
<p>The finding of cancer in the bone of a 1.7-million-year-old human relative isn’t just a biological oddity – it is a reminder of what it means to be both alive and human. Life is fraught with hazards. Thriving biologically (and biographically) does not mean eliminating all risks but managing the ones we can, both to reduce harm and promote a full life.</p><img src="https://counter.theconversation.com/content/63627/count.gif" alt="The Conversation" width="1" height="1" />
Cancer is a deadly disease and would have been particularly lethal before the recent development of effective treatments. So why didn’t it – or our susceptibility to it – die out long ago?Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/600922016-05-30T01:01:02Z2016-05-30T01:01:02ZSometimes the best medicine for a veteran is the company of another veteran<p>Many take time on Memorial Day to remember the Americans who have given their lives in service to our country.</p>
<p>For veterans and their families, that sentiment of remembrance is felt year-round. Many veterans suffer lifelong anguish over the loss of their brothers and sisters in arms. For them, Memorial Day is a day like every other day – a day they remember those who died at war. </p>
<p>This shared grief is just one way some veterans are affected by their military service. Veterans are also molded by military culture – a unique set of values, traditions, language and even humor. Military culture has unique subcultures, but it has enough consistency across different branches, ranks and time periods to make most veterans feel a kinship.</p>
<p>Recognizing this kinship has led veteran service and health care organizations to encourage veterans to build <a href="http://psycnet.apa.org/journals/prj/35/6/470/">trusting relationships</a> and support each other. Researchers have learned that veterans are more likely to share personal information and ask advice about many things, including <a href="http://www.dcoe.mil/content/Navigation/Documents/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf">health care</a>, from fellow veterans. That’s why the VA <a href="http://www.vacareers.va.gov/peer-to-peer/">offers employment</a> to veterans as peer specialists. </p>
<p>I’m a mental health services researcher at the University of Texas at Austin School of Social Work. I focus on increasing the availability of social supports and improving the efficacy of mental health treatment options for veterans and their families. Last year I had the opportunity to study the Texas-funded <a href="http://www.milvetpeer.net/">Military Veteran Peer Network</a>, a statewide program that provides peer-to-peer support in 37 communities. </p>
<p>My research supports the idea that veterans are an important resource who can be trained to support fellow veterans in need. What’s more, I’ve learned that civilian care for veterans can be improved when civilians are trained in military culture. The MVPN offers military-informed care training to civilian providers and law enforcement personnel throughout the state. </p>
<h2>Understanding the need</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The bond that soldiers share can help them stay mentally strong.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/nEKsHK">143d ESC/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Mental health issues are acute for a significant number of veterans.</p>
<p>As many as 25 percent experience <a href="http://www.ptsd.va.gov/public/PTSD-overview/reintegration/overview-mental-health-effects.asp">some form</a> of mental health concern, such as depression. The VA reports that veterans have <a href="http://www.publichealth.va.gov/epidemiology/studies/suicide-risk-death-risk-recent-veterans.asp#sthash.7gh2jBpy.dpuf">a higher risk of suicide</a> compared to the U.S. population. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMra012941">Post-traumatic stress disorder (PTSD)</a> is another well-known concern. Estimates of the prevalence of <a href="http://www.nejm.org/doi/full/10.1056/NEJMra012941">PTSD</a> vary widely due to the variety of study samples and assessment tools. A conservative measure suggests <a href="http://www.psychiatrist.com/jcp/article/Pages/2014/v75n12/v75n1214.aspx">PTSD affects eight percent</a> of service members returning from Afghanistan and Iraq. </p>
<p>Veteran peer support shows promise in addressing these common mental health issues. An example is the Vet to Vet program, a VA program developed by Moe Armstrong, a decorated Vietnam War veteran, in 2002. Research <a href="http://link.springer.com/article/10.1007/s10597-008-9146-7">has shown</a> that veterans who receive peer support have greater levels of empowerment and confidence, improved functioning and reduced alcohol use compared to those who didn’t receive peer support. </p>
<p>Researchers are increasingly understanding the value of incorporating veteran peers into health care teams. Given the large numbers of veterans returning from prolonged combat, the <a href="https://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf">documented shortage</a> of trained behavioral health providers to treat mental health problems, overly <a href="http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html?_r=0.">long wait times</a> for treatment and <a href="http://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2010.61.6.582">stigma felt</a> by veterans regarding seeking help, veteran peer support offers great promise in improving treatment outcomes.</p>
<p>While peer counseling is not new – it was formally recognized in the 1970s –
its value in treating veterans has gained recognition since President George W. Bush’s <a href="http://govinfo.library.unt.edu/mentalhealthcommission/reports/reports.htm">New Freedom Commission on Mental Health</a>, which was released in 2003. </p>
<p>President Barack Obama has also seen the value of peer support. His <a href="https://www.whitehouse.gov/the-press-office/2012/08/31/executive-order-improving-access-mental-health-services-veterans-service">Executive Order 13625</a> of 2012 sought to improve access to mental health services for veterans, service members and military families by including the hiring of peer specialists. As of 2015, the hiring of peer specialists <a href="http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2487">has exceeded</a> the goal set in the executive order. In 2015, President Obama renewed his support by calling for more peer support as part of the <a href="https://www.congress.gov/bill/114th-congress/house-bill/203">Clay Hunt Suicide Prevention for American Veterans Act</a>. </p>
<p>Research on the role of veteran peers has shown their positive impact in assisting homeless veterans to <a href="http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201200100">transition to housing</a>. </p>
<p>There is <a href="http://justiceforvets.org/veteran-mentors">early evidence</a> that veterans charged with misdemeanors and arraigned in Veteran Treatment Courts receive <a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/nejccc35&div=17&id=&page=">invaluable support</a> from veteran peers throughout their probation and treatment for mental health, substance use problems and receive help with housing, transportation and employment. </p>
<p>These are two among many other areas that veteran peers are providing effective supports.</p>
<h2>Getting civilians into the act</h2>
<p>The mental health care provided by civilians for veterans can also benefit from lessons learned from these veteran-driven programs. </p>
<p>Understanding the unique culture shared by military members and their families can be a daunting task for Americans who have not experienced the military lifestyle. Given the volunteer nature of our armed services and the historically small size of our current force, this culture is familiar to only a small proportion of American citizens. Instead of assuming this cultural gap cannot be breached, we are learning the powerful impact that civilian health care professionals can make when they become trained in military culture and practice military-informed care.</p>
<p>Research efforts are underway to understand how to best train practitioners to better understand the clinical impact of this <a href="http://www.jenonline.org/article/S0099-1767%2813%2900411-X/pdf">cultural competency</a>. Research can assess, for example, whether this knowledge can help improve veterans’ engagement in care, increase their treatment completion and improve their clinical outcomes. </p>
<p>The VA has hired <a href="http://www.vacareers.va.gov/peer-to-peer/faqs.asp">800 peers as of 2013</a> with 100 more planned annually. In addition to Texas, New York, Michigan and California, as well as Canada and the United Kingdom, have veteran peer support programs.</p>
<p>Although most of us can never truly understand what war is like, we can honor all veterans, including those who didn’t make it home, by valuing the special knowledge and connection that veterans bring to bear in therapeutic care settings. By prioritizing veterans’ experiences and knowledge, we can build a society that promotes real healing and a respectful homecoming.</p><img src="https://counter.theconversation.com/content/60092/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elisa Borah receives funding from the Patient Centered Outcome Research Institute. She is a Research Associate at the Texas Institute for Excellence in Mental Health at the University of Texas at Austin School of Social Work. </span></em></p>The culture all veterans share may provide the best support for those struggling with mental health issues.Elisa Borah, Research Associate, The University of Texas at AustinLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/512832016-01-21T10:47:06Z2016-01-21T10:47:06ZVeterans’ health care: doctors outside the VA need to know more about the veterans they treat<figure><img src="https://images.theconversation.com/files/108629/original/image-20160119-29783-9x9rju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Civilian doctors might not know that their patients have served in the military. In this photo Marines march around the World Trade Center memorial after participating in a memorial run in 2012.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/nycmarines/7301497232/in/dateposted/">MarineCorps NewYork/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Each year the military discharges over <a href="https://www.whitehouse.gov/sites/default/files/docs/military_credentialing_and_licensing_report_2-24-2013_final.pdf">240,000 veterans</a> to reintegrate into civilian society. It’s a professional transition, but it’s also a personal one. </p>
<p>Veterans go from <a href="http://www.tricare.mil/">TRICARE</a>, the Department of Defense’s own health care system, to navigating the ins and outs of the civilian health care system. Under TRICARE, military service members are cared for in a manner that meets their needs. When they’re discharged, their new health care providers might not know that they were ever in the military.</p>
<p>Asking “Have you served in the military?” may seem like a minor issue, but it’s actually much more important than you might think. And it’s a question that few doctors make a point of <a href="http://dx.doi.org/10.1097/ACM.0000000000000367">asking</a>, even though many medical residents and medical students receive <a href="http://www.va.gov/oaa/gme_default.asp">all or part of their clinical training</a> at VA medical centers and hospitals.</p>
<p>In fact, Jeffrey Brown, a professor at Weill Cornell Medical College and a Vietnam veteran, has called it the “<a href="http://jama.jamanetwork.com/article.aspx?articleid=1391922">unasked question</a>.” When physicians don’t ask, they may miss critical parts of their patient’s medical history, making it harder to provide the best possible care.</p>
<h2>Why ‘Have you served?’ is a critical question</h2>
<p>Contrary to popular belief, most veterans do not receive care from the Veterans Health Administration (VHA) health care system. While eligibility criteria to receive VA care have become more flexible for combat veterans in recent years, overall most veterans don’t go the VA. Only about <a href="http://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2013.pdf">30 percent</a> receive health care from the VA after they are discharged. Some might not be eligible for VA health care, or don’t live near a VA health care center. Others might prefer to go somewhere else for care. </p>
<p>The health care providers might not be aware of the chemicals, infections and injuries that military personnel can encounter. Veterans may have been exposed to chemical pollutants or solvents (such as jet fuel, nerve agents or radiation) as well as infectious diseases and blood-borne pathogens. During their careers, they may have also gotten blast injuries, burns or shrapnel wounds. They may also face reproductive health issues or dermatologic issues related to their service. Some may have physical injuries, mental and emotional issues or any combination of these. </p>
<p>Unlike many of our perceptions of the wounds of war – loss of limb or damage to some other body part – veterans also suffer from invisible wounds such as post-traumatic stress disorder (PTSD), military sexual trauma (MST) and traumatic brain injury (TBI), a common wound of Operation Enduring Freedom/Operation Iraqi Freedom. </p>
<p>Veterans may also have experienced physical and emotional trauma, as well as stress from adjustment back to civilian life. For instance, 17 percent of all veterans seeking care at the VA have depression, and 13 percent of Operation Iraqi Freedom combat veterans screen positive for depression within six months of returning from combat. </p>
<p>So asking “Did you ever serve in the military” is an important start. If a patient says yes, then providers should follow up by asking when and where they served and what they did. This can help health care providers arrive at the cause of symptoms, pinpoint sources of support and barriers to wellness. This kind of background information can help providers identify the best medical approaches and develop an effective care plan for veterans and <a href="http://www.army.mil/article/147786/Experts_explain_mental_state_of_military_children/">their families</a>.</p>
<p>Part of making sure that doctors ask their patients this critical question is to teach them who veterans are. </p>
<h2>Using photographs to teach doctors about veterans</h2>
<p>As medical educators and researchers working at the University of Michigan Medical School who also have experience working with veterans, we know how important it is for health care providers to be aware of their patients’ military service. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=873&fit=crop&dpr=1 600w, https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=873&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=873&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1097&fit=crop&dpr=1 754w, https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1097&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/108615/original/image-20160119-29766-1noz1jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1097&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">While serving.</span>
<span class="attribution"><span class="source">Paula T Ross</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>So we developed a massive open online course (MOOC) called <a href="http://digitaleducation.umich.edu/dei/va-centered-care/">Lessons in Veteran-Centered Care</a> aimed at teaching health professionals about providing veteran-centered care. We cover military culture, focusing on patients’ positive capabilities and strengths, and military health history, as well as highlighting available patient resources.</p>
<p>Participants learn how to use and apply principles from the course to improve assessment and triage for patients with PTSD, MST, TBI, anxiety and depression – all the conditions that are more prevalent in the military population than in the general civilian one. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=784&fit=crop&dpr=1 600w, https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=784&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=784&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=985&fit=crop&dpr=1 754w, https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=985&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/108616/original/image-20160119-29754-17yo19o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=985&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">…and as a veteran.</span>
<span class="attribution"><span class="source">Paula T Ross</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But caring for veterans isn’t just about being able to diagnose PTSD or depression. It’s also about understanding who they are and where they’ve been. To do this we use <a href="https://www.mededportal.org/publication/9818">coursework</a> and key moments from the documentary “<a href="http://www.wheresoldierscomefrom.com/">Where Soldiers Come From</a>,” which follows five young men as they joined the National Guard, underwent military training, deployed to Afghanistan looking for improvised explosive devices and returned home as combat veterans dealing with PTSD and TBI. </p>
<p>To help health professionals understand how diverse today’s veterans are, we also use 30 pairs of photographs of people during and after their time in service. The collection includes veterans from World War II, the Korean War, the Vietnam War, Desert Storm/Desert Shield and the more recent conflicts in Iraq and Afghanistan. This exercise alone helps demonstrate the age diversity of today’s veterans, most of whom fall between 35 and 74 years old. </p>
<p>The collection also includes several women. Women now make up <a href="http://online.liebertpub.com/doi/pdfplus/10.1089/jwh.2015.5530">an increasing portion</a> of veterans, more than <a href="http://www1.va.gov/womenvet/docs/WomenVeteransPopulationFactSheet.pdf">two million today</a>, about <a href="http://www.va.gov/vetdata/docs/SpecialReports/Final_Womens_Report_3_2_12_v_7.pdf">nine percent of all veterans</a>.</p>
<p>Although men have dominated the veteran population in the past, an increasing number of women have served in recent conflicts. The photographs also illustrate the racial diversity of today’s veterans. About <a href="http://www.va.gov/vetdata/docs/SpecialReports/Minority_Veterans_2013.pdf">21 percent</a> of veterans are minorities. </p>
<p>These photos help medical students and physicians in our course visualize the trajectory of US service members from soldier to civilian. We challenge learners to think deeply about the experiences, concerns and perspectives of U.S. military veterans, and to reshape previously held unconscious biases, stereotypes or attitudes toward veterans.</p>
<p>Our goal is to use our photographs to improve veteran care by asking health care professionals to take a similar yet important step, and consider military service or exposure to the military culture during their encounters with all patients. </p>
<p>Medical students who’ve taken the course said it inspired them to be more likely to ask patients if they’ve served and to understand the importance of veteran-centered care. Faculty physicians who took the course said it made them reexamine their own biases about veterans. </p>
<p>Ultimately, we challenge assumptions about what veterans look like and help health care professionals recognize that most veterans look just like other patients. Unless you ask the question, you may never find out this valuable piece of information that can lead to improving health outcomes.</p><img src="https://counter.theconversation.com/content/51283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monica L. Lypson, MD MHPE is the Associate Chief of Staff for Education at the Ann Arbor Veteran Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.</span></em></p><p class="fine-print"><em><span>Paula Thompson Ross does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Asking ‘Have you served in the military?’ may seem like a minor issue, but it’s actually much more important than you might think. And it’s a question that few doctors make a point of asking.Monica Lypson, Professor of Internal Medicine and Learning Health Sciences, University of MichiganPaula Thompson Ross, Director of Advancing Scholarship, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/422252015-06-01T05:17:20Z2015-06-01T05:17:20ZHow understanding breast cancer at a molecular level is revolutionising our thinking<figure><img src="https://images.theconversation.com/files/83245/original/image-20150528-31337-1kdfzft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The many presentations of breast cancer. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-128042738/stock-photo-close-up-topless-woman-body-covering-her-breast-with-hand-color-processed.html?src=PLpv-uwjPddclgmb5dZtWw-1-18">Breast cancer by Shutterstock</a></span></figcaption></figure><p>The evolution of past and modern therapies in breast cancer has been an inspiring illustration of the progress that has been made towards cancer cures. Breast cancer makes up a quarter of new cases worldwide and is <a href="http://www.wcrf.org/int/cancer-facts-figures/worldwide-data">the most common cancer in women</a>. </p>
<p>While the number of people with breast cancer <a href="https://theconversation.com/hard-evidence-are-we-beating-cancer-20870">has been increasing</a> fewer people are dying from the disease, potentially because of <a href="http://www.cancerscreening.nhs.uk/breastscreen/">better screening</a> and diagnosis at an early and more curable stage. Thanks to better treatments, more people are also surviving five years after diagnosis, but this wouldn’t be possible with the strides that have been made in understanding breast cancer at a molecular level. </p>
<p>Breast cancer was long considered as a tumour with an underlying relationship with oestrogen. Instead, driven by a greater understanding of the molecular basis of breast cancers, we now see a more complex picture. We now know breast cancer to be an umbrella of different diseases – as many as ten different types – with a number of subtypes.</p>
<p>And although a number of factors can contribute towards developing breast cancer, there is no single agent or cause. A closer look at cancer detection, molecular biology and progression is telling us more about the underlying factors in breast cancer development and spread.</p>
<h2>No one breast cancer</h2>
<p>Despite the uncertainties of what exactly causes breast cancer, there is abundant <a href="http://www.ncbi.nlm.nih.gov/pubmed/23543779">evidence for hormonal</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12133652">reproductive factors</a>. A number <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470027">of environmental factors</a> may also lead to mutations in DNA, such as exposure to radiations, chemicals and alcohol. However not all of the mutations are environmentally induced – some occur spontaneously. Other factors that increase risk of developing breast cancers are age, gender, family history and certain medical conditions. </p>
<p>A wide range of genes and proteins may contribute towards the development of breast cancer or fail to prevent it; these can be either involved in regulating the cell cycle, promoting the growth of tumour cells (known as oncogenes) or suppressing tumour cell growth (known as tumour suppress genes). There are also genes that are involved in <a href="https://theconversation.com/how-self-destructing-cells-may-hold-key-to-cancer-cure-31707">promoting cell death</a> along with genes involved in DNA repair. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=722&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=722&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=722&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=907&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=907&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=907&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">BRCA1.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:BRCA1_en.png">Kuebi = Armin Kübelbeck</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>For example, inherited breast cancers can involve mutations in BRCA1 and BRCA2, genes that are crucial in DNA repair. Mutations in these genes result in incorrect repair of DNA damage which in consequence increases risk of further mutations occurring that may then lead to cancer. Genetic tests <a href="https://theconversation.com/greater-access-to-genetic-testing-in-nhs-will-help-cancer-fight-14448">are now available</a> to test for such genes, which are known to increase the risk of developing breast cancer by 40-90%. </p>
<h2>Four subtypes</h2>
<p>Gene expression <a href="http://www.news-medical.net/health/What-is-Gene-Expression.aspx">is the process</a> in which genetic instructions are used to make gene products, mainly proteins that function as enzymes, hormones and receptors. Gene expression profiling is a technique that allows scientists to determine the expression levels of hundreds or thousands of genes within a cell. </p>
<p>Breast cancer cells <a href="http://www.macmillan.org.uk/information-and-support/breast-cancer/treating/treatment-decisions/Understanding-your-diagnosis/receptors-for-breast-cancer.html">have receptors</a> that other hormones or proteins can attach to and stimulate the cancer to grow. These receptors include the hormones oestrogen and progesterone, and human epidermal growth factor 2 (HER2), a protein. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Expression of oestrogen sulfotransferase 1E1 and steroid sulfatase in breast cancer.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-128042738/stock-photo-close-up-topless-woman-body-covering-her-breast-with-hand-color-processed.html?src=PLpv-uwjPddclgmb5dZtWw-1-18">Libertas Academica</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The expression of breast cancer receptors has led to the molecular classification of breast cancer into four distinct subtypes: basal type or triple negative breast cancers (TNBC), HER2 positive breast cancers, Luminal A and Luminal B breast cancers – each with a different combination of positive/negative receptor interactions. </p>
<p>A Luminal B type cancer will be positive and/or negative for oestrogen receptors and positive for HER2, for example, while triple negative breast cancers are those that do not have receptors for either HER2 or for the hormones oestrogen and progesterone, and affects about a fifth of women with breast cancer.</p>
<p>Establishing the presence of these receptors can allow clinicians to make more accurate prognosis and work out which treatments will be more effective for particular patients. For example, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23320171">20-30% of breast cancers</a> are known to be HER2 positive, which indicates a poorer prognosis with a reduced overall survival rate.</p>
<p>Some breast cancers are more common in particular populations, for example the occurrence of triple negative breast cancers is thought <a href="http://annonc.oxfordjournals.org/content/23/suppl_6/vi7.long">to be three times higher</a> in women of African descent and usually more aggressive than in European women, there is <a href="http://www.nature.com/nrc/journal/v15/n4/full/nrc3896.html#close">still some debate</a> over wheather this is due to lifestyle (enviromental) factors or biological reasons.</p>
<h2>Targeted therapies</h2>
<p>Targeted therapies tend to target a specific protein or receptor found in tumour cells making the treatment selective and more effective. So while HER2 positive breast cancers have a poorer prognosis, treatment has improved through targeted therapies such as Herceptin, which fights against cancer cells by suppressing the function of HER2 to prevent tumour growth.</p>
<p>Unlike chemotherapy and radiotherapy, which affects both normal and cancerous cells, using targeted therapy reduces overall side effects. But it isn’t perfect – some patients still don’t respond to targeted therapy and there can be resistance to the drug in some cases. <a href="https://theconversation.com/cutting-edge-particle-physics-could-bring-cancer-therapy-home-13765">New technology</a> such as proton beam therapy may provide a more targeted form of radiotherapy. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Internal radiotherapy for breast cancer.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:Diagram_showing_how_you_have_internal_radiotherapy_for_breast_cancer_CRUK_159.svg">Cancer Research UK/Wikimedia Commons</a></span>
</figcaption>
</figure>
<h2>The gene trail</h2>
<p>In addition to BRCA1 and BRCA2, <a href="http://www.breastcancer.org/risk/factors/genetics">a number of genes</a> – though rarer – that increase the risk of breast cancer when faulty have been identified. These include the ATM gene – which helps repair damaged DNA, the CDH1 gene – which makes a protein that helps cells join together to form tissue, and the CHEK2 gene – which helps create instructions for a protein that stops tumour growth. A paper in Nature Genetics recently <a href="http://medicalxpress.com/news/2015-04-breast-cancer-gene.html">identified a new breast cancer gene</a> called RECQL, mutations in which are associated with breast cancer. </p>
<p>There may yet be more. Around 5-10% of all breast cancer cases <a href="http://www.breastcancer.org/risk/factors/genetics">are hereditary</a>, and while diagnostic or genetic tests are available for some genes, there are yet to be any for some of the others already identified.</p>
<p>Although molecular subtyping of breast cancer has been proven to be useful with more patient-specific treatments, the techniques used to classify breast cancers into these subtypes can vary from place to place. Triple negative breast cancers may be the most reliably classified and identified, whereas other subtypes may have some variance. Changes in receptor status, for example, can also occur throughout the progression of the disease and in some cases equivocal results – which is seen in some HER2 testing – can make it uncertain what subtype the patient belongs to and what treatment they should have, or what the results might be.</p>
<p>Understanding breast cancer at a molecular level opens up the way for better treatments, but we’re also discovering just how complex these cancers are. In the long run, the more detailed knowledge we have the better.</p><img src="https://counter.theconversation.com/content/42225/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Haroon Hussain does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Long gone are the days when breast cancer was seen as a tumour with an underlying relationship with oestrogen. The picture is much more complex.Haroon Hussain, PhD Student, Brunel University LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/400362015-04-20T05:04:49Z2015-04-20T05:04:49ZThe mystery of breast cancer<p>For most of the common cancers, a major cause has been identified: smoking causes <a href="http://med.stanford.edu/biostatistics/abstract/RobertProctor_paper1.pdf">90% of lung cancer worldwide</a>, hepatitis viruses cause most liver cancer, <em>H pylori</em> bacteria <a href="http://www.ncbi.nlm.nih.gov/pubmed/24889903">causes stomach cancer</a>, Human papillomavirus causes almost all cases of <a href="http://www.cdc.gov/cancer/hpv/statistics/cases.htm">cervical cancer</a>, colon cancer is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22158327">largely explained</a> by physical activity, diet and family history. </p>
<p>But for breast cancer, there is no smoking gun. It is almost unique among the common cancers of the world in that there is not a known major cause; there is no consensus among experts that proof of a major cause has been identified. </p>
<p>Yet, breast cancer is the most common form of cancer in <a href="http://www.who.int/mediacentre/factsheets/fs297/en/">women worldwide</a>. The risk <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">is not equally distributed</a> around the globe, though. Women in North America and Northern Europe have long had five times the risk of women in Africa and Asia, though recently risk has been increasing fast in Africa and Asia for unknown reasons. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Was it something I ate?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-2024202/stock-photo-supermarket.html?src=uWWE4rUoHUIzS65Kzhlheg-3-12">Supermarket aisle via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Is diet to blame?</h2>
<p>Up until about 20 years ago, we thought it was all about diet. As people abandon their local food sources and begin to eat highly processed foods with lots of fats, the hypothesis went, breast cancer was thought to be more likely to develop. </p>
<p>This hypothesis was logical because when researchers analyzed countries’ per capita fat consumption and breast cancer mortality rates, they found a <a href="http://cancerres.aacrjournals.org/content/35/11_Part_2/3374">strong correlation</a>. In addition, rats fed a high-fat diet are more prone to breast tumors. </p>
<p>By studying Japanese migrants to California, researchers found that the first generation had low risk like their parents in Japan, but then by the second and third generation, <a href="http://www.ncbi.nlm.nih.gov/pubmed/7742407">risk was as high</a> as white American women. So, the genetics of race did not account for the stark differences in the breast cancer risk between Asia and America. This was also consistent with the idea that the change in food from the lean Asian diet to the high-fat American diet causes cancer. So it all made sense.</p>
<p>Until it didn’t. </p>
<h2>Diet studies find that fat is not the answer</h2>
<p>Starting in the mid-1980s, large, well-done prospective studies of diet and breast cancer began to be reported, and they were uniformly negative. Fat in the diet of adult women <a href="http://www.ncbi.nlm.nih.gov/pubmed/3785347">had no impact</a> on breast cancer risk at all. </p>
<p>This was very surprising – and very disappointing. The evidence for other aspects of diet, like fruits and vegetables, has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/24330083">mixed</a>, though alcohol consumption does increase risk modestly. It is also clear that heavier women are at higher risk after menopause which might implicate the total amount of calories consumed if not the composition of the diet. </p>
<p>There is a chance that early life dietary fat exposure, even in utero, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9823005">may be important</a>, but it’s difficult to study in humans, so we don’t know much about how it might relate to breast cancer risk later in life. </p>
<p>If diet is not the major cause of breast cancer, then what else about modernization might be the culprit? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some risk factors, like exercise, can be modified.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-175183394/stock-photo-fit-sports-woman-jogging-at-park.html?src=h_0DMjDoxgREWJUukUoIEQ-1-0">Runner via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Two kinds of risk factors: what we can modify, and what we can’t</h2>
<p>The factors shown to affect a woman’s risk for developing breast cancer fall into <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors">two categories</a>. First, those that cannot be easily modified: age at menarche, age at birth of first child, family history, genes like BRCA1. And second, those that are modifiable: exercise, body weight, alcohol intake, night-work jobs. </p>
<p>The role of environmental pollution is controversial and also <a href="http://www.ncbi.nlm.nih.gov/pubmed/24818537">difficult to study</a>. The concern about chemicals, particularly endocrine disruptors, started after the realization that such chemicals could affect cancer risk in <a href="http://www.niehs.nih.gov/health/topics/agents/endocrine/">rodent models</a>. But in human studies the evidence is mixed.</p>
<p>Because child bearing at a young age and breast feeding reduce risk, the incidence throughout Africa, where birth rates tend to be higher, and where women start their families at younger ages, <a href="http://www.who.int/bulletin/volumes/91/9/13-020913/en/">has been lower</a>. </p>
<p>Death rates, however, from breast cancer in sub-Saharan Africa are now almost as high as in the developed world <a href="http://www.ncbi.nlm.nih.gov/pubmed/24604092">despite the incidence still being much lower</a>. This is because in Africa, women are diagnosed at a later stage of disease and also because there are far fewer treatment options.</p>
<p>The question is whether the known risk factors differ enough between the high-risk modern societies and the low-risk developing societies to account for the large differences in risk. The answer: probably not. Experts think that less than half the high risk in America is explained by the <a href="http://www.ncbi.nlm.nih.gov/pubmed/7473816">known risk factors</a>, and that these factors explain <a href="http://www.ncbi.nlm.nih.gov/pubmed/2228308">very little of the difference</a> in risk with Asia. </p>
<p>A related question is whether the high risk in America and Northern Europe is due to a combination of many known exposures, each of which affects risk a little bit, or mostly due to a major cause that has so far eluded detection. And maybe some of the known risk factors have a common cause which we don’t yet understand. </p>
<h2>Are we just finding more cancer?</h2>
<p>Since the 1980s, screening by mammography has accounted for some of the increase in incidence in the modern world compared to the developing world, but not nearly enough to explain the entire difference. About 20% of the cancers found by mammography are now believed to be of a type that would never have progressed beyond the very small early stage that mammography can detect. But the problem is that we can’t tell which are the benign <a href="http://jama.jamanetwork.com/article.aspx?articleid=1853165">ones and which are not</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Electric light and shift work may be factors.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-146043281/stock-photo-side-view-of-a-young-woman-working-on-computer-in-dark-office.html?src=R6VnowHB7Nqr7vQwuzgxsg-1-19">Office worker via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>What about electric light?</h2>
<p>Electric light is a hallmark of modern life. So, maybe the introduction and increasing use of electricity to light the night accounts for a portion of the worldwide breast cancer burden.</p>
<p>This might be because our circadian rhythm is disrupted, which affects hormones that <a href="http://onlinelibrary.wiley.com/doi/10.3322/caac.21218/abstract">influence breast cancer development</a>. For example, electric light at night can trick the body into daytime physiology in which the hormone melatonin is suppressed; and melatonin has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/16322268">shown</a> to have a strong inhibitory effect on human breast tumors growing in rats.</p>
<p>The theory is easy to state but difficult to test in a rigorous manner. Studies have shown that night-working women are at <a href="http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2807%2970373-X/abstract">higher risk than day-working women</a>, which was the first prediction of the theory. </p>
<p>Other predictions are that blind women would be at lower risk, short sleepers would be at higher risk, and more highly lighted communities at night would have higher breast cancer incidence. Each of these has some modest support though <a href="http://www.ncbi.nlm.nih.gov/pubmed/19380369">none are conclusive</a>. What we do know is that electric light in the evening or at night can <a href="https://theconversation.com/a-dark-night-is-good-for-your-health-39161">disrupt our circadian rhythms</a>, and whether this harms our long term health, including risk of breast cancer, is not yet clear.</p>
<p>Whatever is going on, it’s important to find answers because breast cancer has become a scourge that now afflicts women all over the world in very large numbers, at almost two million new cases this year alone.</p><img src="https://counter.theconversation.com/content/40036/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Stevens has received funding from the National Institute for Environmental Health Sciences.</span></em></p>Major causes have been identified for most common cancers, like liver and lung. But we still haven’t identified one for breast cancer.Richard G. "Bugs" Stevens, Professor, School of Medicine, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/148202013-06-07T04:28:18Z2013-06-07T04:28:18ZExplainer: why do women go through menopause?<figure><img src="https://images.theconversation.com/files/25151/original/pb6qq2s7-1370500692.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One suggestion is that menopause enables women to provide for their grandchildren.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>Menstruation is a reproductive quirk that humans share with only a few other mammals. But even stranger is the fact that women stop menstruating when they have a whole third of their lives left to live. </p>
<p>All animals have a finite reproductive life. But more often than not, their reproductive system winds down at roughly the same time as every other system in the body – the menopausal killer whale is a notable exception.</p>
<p>The ability to bear children gradually declines throughout a woman’s reproductive life. The <a href="http://www.ncbi.nlm.nih.gov/pubmed/12099629">average age</a> at which a woman’s ability to natural conceive ceases is 38. </p>
<p>But when the fertility free-fall of menopause kicks in between the ages of 45 and 55, complete sterility is the inevitable result. No more ovulation, no more menstruation, and no more opportunities to procreate. </p>
<p>In contrast, males experience only a slight decrease in fertility in their senior years.</p>
<h2>Giving kids a head start</h2>
<p>Evolutionary theory predicts that life span and reproductive span should synchronise – why go on living if you are unable to go on breeding, bolstering the contribution of your genes to the next generation?</p>
<p>One reason for dialling back reproduction could be to <a href="http://www.jstor.org/discover/10.2307/2406060?uid=3737536&uid=2&uid=4&sid=21102078205003">maximise the level of nurturing</a> available for children that already exist. Human infancy is marked for its length and also for the degree of dependence that infants have on their parents. Perhaps menopause is a reproductive compromise to ensure that a woman’s last born makes it out of the nest safely. </p>
<p>But this would only account for a ten or 15 year difference between menopause and death – much less than usually occurs.</p>
<h2>Grandmothers and daughters-in-law</h2>
<p>Another suggestion – <a href="http://www.ncbi.nlm.nih.gov/pubmed/9448332">dubbed the grandmother hypothesis</a> – is that menopause enables women to provide for their grandchildren. </p>
<p>In evolutionary terms, a person is said to be “fit” if they are able to pass on their genes to future generations by reproducing. Given that our children bare 50% of our genes - the other 50% from our partner - and our grandchildren share 25% of our genes, a grandmother providing for her grandchildren still results in evolutionary fitness. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1105&fit=crop&dpr=1 600w, https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1105&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1105&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1389&fit=crop&dpr=1 754w, https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1389&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/25153/original/g9zzmjnk-1370501096.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1389&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A more recent hypothesis centres on the age-old conflict between women and their mothers-in-law.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The numbers don’t add up, though. The fitness benefit of caring for grandchildren is less direct and, in the end, less potent than if the grandmother were simply able to have more children of her own.</p>
<p>A more recent hypothesis centres on the age-old <a href="http://dx.doi.org/10.1073/pnas.0711911105">conflict between women and their mothers-in-law</a>. This intergenerational reproductive argy-bargy is apparently the result of ancestral daughters-in-law joining a partner’s family. The daughter-in-law gains nothing by helping her partner’s mother to reproduce, but the mother-in-law does benefit in an evolutionary sense by helping her own grandchildren to be raised. </p>
<p>Instead of having two competing females in the one clan reproducing, the older female relinquishes her own reproduction in favour of helping her daughter-in-law raise her grandkids.</p>
<p>Similarly to the grandmother hypothesis, the reproductive conflict hypothesis could explain why reproduction ceases at around the same time as a woman reaches the age at which she is likely to become a grandmother. </p>
<p>But a recent study of pre-industrial <a href="http://www.ncbi.nlm.nih.gov/pubmed/23403380">Norwegian women</a> casts doubt on this reckoning of evolutionary events. The study found that grandmothers who had a reproductive overlap with their daughters-in-law had more grandchildren, not less.</p>
<h2>A fluke of nature</h2>
<p>So, perhaps it is to happenstance that we must turn for an explanation for menopause. Could it be that menopause is simply an evolutionary hitchhiker; a trait that has come along for the ride without providing any adaptive benefit?</p>
<p>It’s possible, for example, that menopause could be the result of a physiological trade-off that favours efficient reproduction early on.</p>
<p>In searching for an answer to why women live for so long post-fertility, palaeontology has reminded us of a very important fact: <a href="http://www.ncbi.nlm.nih.gov/pubmed/11393331">old age is actually relatively new age</a>. Early human fossils are invariably young, and it wasn’t until a few thousand years ago that anyone lived into the senior years we have now grown to expect. </p>
<p>It is highly likely, therefore, that our long-lost great-great grannies didn’t live long enough to experience the hot flushes, night swears and yo-yo-ing hormones of the modern-day menopause. They never lived long enough to be denied the children that menopause robbed them of, because they may not have reached menopausal age at all. </p>
<p>We can be thankful for our longer lives, but menopause may be the cost women endure for it.</p><img src="https://counter.theconversation.com/content/14820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dyani Lewis receives funding from the Department of Health and Ageing.</span></em></p>Menstruation is a reproductive quirk that humans share with only a few other mammals. But even stranger is the fact that women stop menstruating when they have a whole third of their lives left to live…Dyani Lewis, Sexual health researcher, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.