Compensatory Education: Approaching the Problem from the Wrong Direction

*Designated as an exemplary master's project for 2015-16*

Electronic health records: essential tools in integrating substance abuse treatment with primary care.

While substance use problems are considered to be common in medical settings, they are not systematically assessed and diagnosed for treatment management. Research data suggest that the majority of individuals with a substance use disorder either do not use treatment or delay treatment-seeking for over a decade. The separation of substance abuse services from mainstream medical care and a lack of preventive services for substance abuse in primary care can contribute to under-detection of substance use problems. When fully enacted in 2014, the Patient Protection and Affordable Care Act 2010 will address these barriers by supporting preventive services for substance abuse (screening, counseling) and integration of substance abuse care with primary care. One key factor that can help to achieve this goal is to incorporate the standardized screeners or common data elements for substance use and related disorders into the electronic health records (EHR) system in the health care setting. Incentives for care providers to adopt an EHR system for meaningful use are part of the Health Information Technology for Economic and Clinical Health Act 2009. This commentary focuses on recent evidence about routine screening and intervention for alcohol/drug use and related disorders in primary care. Federal efforts in developing common data elements for use as screeners for substance use and related disorders are described. A pressing need for empirical data on screening, brief intervention, and referral to treatment (SBIRT) for drug-related disorders to inform SBIRT and related EHR efforts is highlighted.

Full of Hot Air? Three Examinations of Climate Change in the American Political Information Environment

Climate change is thought to be one of the most pressing environmental problems facing humanity. However, due in part to failures in political communication and how the issue has been historically defined in American politics, discussions of climate change remain gridlocked and polarized. In this dissertation, I explore how climate change has been historically constructed as a political issue, how conflicts between climate advocates and skeptics have been communicated, and what effects polarization has had on political communication, particularly on the communication of climate change to skeptical audiences. I use a variety of methodological tools to consider these questions, including evolutionary frame analysis, which uses textual data to show how issues are framed and constructed over time; Kullback-Leibler divergence content analysis, which allows for comparison of advocate and skeptical framing over time; and experimental framing methods to test how audiences react to and process different presentations of climate change. I identify six major portrayals of climate change from 1988 to 2012, but find that no single construction of the issue has dominated the public discourse defining the problem. In addition, the construction of climate change may be associated with changes in public political sentiment, such as greater pessimism about climate action when the electorate becomes more conservative. As the issue of climate change has become more polarized in American politics, one proposed causal pathway for the observed polarization is that advocate and skeptic framing of climate change focuses on different facets of the issue and ignores rival arguments, a practice known as “talking past.” However, I find no evidence of increased talking past in 25 years of popular newsmedia reporting on the issue, suggesting both that talking past has not driven public polarization or that polarization is occurring in venues outside of the mainstream public discourse, such as blogs. To examine how polarization affects political communication on climate change, I test the cognitive processing of a variety of messages and sources that promote action against climate change among Republican individuals. Rather than identifying frames that are powerful enough to overcome polarization, I find that Republicans exhibit telltale signs of motivated skepticism on the issue, that is, they reject framing that runs counter to their party line and political identity. This result suggests that polarization constrains political communication on polarized issues, overshadowing traditional message and source effects of framing and increasing the difficulty communicators experience in reaching skeptical audiences.

Unnatural History: Ecological Temporality in Post-1945 American Literature

While environmental literary criticism has traditionally focused its attention on the textual representation of specific places, recent ecocritical scholarship has expanded this focus to consider the treatment of time in environmental literature and culture. As environmental scholars, activists, scientists, and artists have noted, one of the major difficulties in grasping the reality and implications of climate change is a limited temporal imagination. In other words, the ability to comprehend and integrate different shapes, scales, and speeds of history is a precondition for ecologically sustainable and socially equitable responses to climate change.

My project examines the role that literary works might play in helping to create such an expanded sense of history. As I show how American writers after 1945 have treated the representation of time and history in relation to environmental questions, I distinguish between two textual subfields of environmental temporality. The first, which I argue is characteristic of mainstream environmentalism, is disjunctive, with abrupt environmental changes separating the past and the present. This subfield contains many canonical works of postwar American environmental writing, including Aldo Leopold’s A Sand County Almanac, Edward Abbey’s Desert Solitaire, Annie Dillard’s Pilgrim at Tinker Creek, and Kim Stanley Robinson’s Science in the Capital trilogy. From treatises on the ancient ecological histories of particular sites to meditations on the speed of climate change, these works evince a preoccupation with environmental time that has not been acknowledged within the spatially oriented field of environmental criticism. However, by positing radical breaks between environmental pasts and environmental futures, they ultimately enervate the political charge of history and elide the human dimensions of environmental change, in terms both of environmental injustice and of possible social responses.

By contrast, the second subfield, which I argue is characteristic of environmental justice, is continuous, showing how historical patterns persist even across social and ecological transformations. I trace this version of environmental thought through a multicultural corpus of novels consisting of Ralph Ellison’s Invisible Man, Ishmael Reed’s Mumbo Jumbo, Helena María Viramontes’ Under the Feet of Jesus, Linda Hogan’s Solar Storms, and Octavia Butler’s Parable of the Sower and Parable of the Talents. Some of these novels do not document specific instances of environmental degradation or environmental injustice and, as a result, have not been critically interpreted as relevant for environmental analysis; others are more explicit in their discussion of environmental issues and are recognized as part of the canon of American environmental literature. However, I demonstrate that, across all of these texts, counterhegemonic understandings of history inform resistance to environmental degradation and exploitation. These texts show that environmental problems cannot be fully understood, nor environmental futures addressed, without recognizing the way that social histories of inequality and environmental histories of extraction continue to structure politics and ecology in the present.

Ultimately, then, the project offers three conclusions. First, it suggests that the second version of environmental temporality holds more value than the first for environmental cultural studies, in that it more compellingly and accurately represents the social implications of environmental issues. Second, it shows that “environmental literature” is most usefully understood not as the literature that explicitly treats environmental issues, but rather as the literature that helps to produce the sense of time that contemporary environmental crises require. Third, it shows how literary works can not only illuminate the relationship between American ideas about nature and social justice, but also operate as a specifically literary form of eco-political activism.

Globalizing the Sculptural Landscapes of the Sarapis and Isis Cults in Hellenistic and Roman Greece

“Globalizing the Sculptural Landscape of Isis and Sarapis Cults in Roman Greece,” asks questions of cross-cultural exchange and viewership of sculptural assemblages set up in sanctuaries to the Egyptian gods. Focusing on cognitive dissonance, cultural imagining, and manipulations of time and space, I theorize ancient globalization as a set of loosely related processes that shifted a community's connections with place. My case studies range from the 3rd century BCE to the 2nd century CE, including sanctuaries at Rhodes, Thessaloniki, Dion, Marathon, Gortyna, and Delos. At these sites, devotees combined mainstream Greco-Roman sculptures, Egyptian imports, and locally produced imitations of Egyptian artifacts. In the last case, local sculptors represented Egyptian subjects with Greco-Roman naturalistic styles, creating an exoticized visual ideal that had both local and global resonance. My dissertation argues that the sculptural assemblages set up in Egyptian sanctuaries allowed each community to construct complex narratives about the nature of the Egyptian gods. Further, these images participated in a form of globalization that motivated local communities to adopt foreign gods and reinterpret them to suit local needs.

I begin my dissertation by examining how Isis and Sarapis were represented in Greece. My first chapter focuses on single statues of Egyptian gods, describing their iconographies and stylistic tendencies through examples from Corinth and Gortyna. By comparing Greek examples with images of Sarapis, Isis, and Harpokrates from around the Mediterranean, I demonstrate that Greek communities relied on globally available visual tropes rather than creating site or region-specific interpretations. In the next section, I examine what other sources viewers drew upon to inform their experiences of Egyptian sculpture. In Chapter 3, I survey the textual evidence for Isiac cult practice in Greece as a way to reconstruct devotees’ expectations of sculptures in sanctuary contexts. At the core of this analysis are Apuleius’ Metamorphoses and Plutarch’s De Iside et Osiride, which offer a Greek perspective on the cult’s theology. These literary works rely on a tradition of aretalogical inscriptions—long hymns produced from roughly the late 4th century B.C.E. into the 4th century C.E. that describe the expansive syncretistic powers of Isis, Sarapis, and Harpokrates. This chapter argues that the textual evidence suggests that devotees may have expected their images to be especially miraculous and likely to intervene on their behalf, particularly when involved in ritual activity inside the sanctuary.

In the final two chapters, I consider sculptural programs and ritual activity in concert with sanctuary architecture. My fourth chapter focuses on sanctuaries where large amounts of sculpture were found in underground water crypts: Thessaloniki and Rhodes. These groups of statues can be connected to a particular sanctuary space, but their precise display contexts are not known. By reading these images together, I argue that local communities used these globally available images to construct new interpretations of these gods, ones that explored the complex intersections of Egyptian, Greek, and Roman identities in a globalized Mediterranean. My final chapter explores the Egyptian sanctuary at Marathon, a site where exceptional preservation allows us to study how viewers would have experienced images in architectural space. Using the Isiac visuality established in Chapter 3, I reconstruct the viewer's experience, arguing that the patron, Herodes Atticus, intended his viewer to inform his experience with the complex theology of Middle Platonism and prevailing elite attitudes about Roman imperialism.

Throughout my dissertation, I diverge from traditional approaches to culture change that center on the concepts of Romanization and identity. In order to access local experiences of globalization, I examine viewership on a micro-scale. I argue that viewers brought their concerns about culture change into dialogue with elements of cult, social status, art, and text to create new interpretations of Roman sculpture sensitive to the challenges of a highly connected Mediterranean world. In turn, these transcultural perspectives motivated Isiac devotees to create assemblages that combined elements from multiple cultures. These expansive attitudes also inspired Isiac devotees to commission exoticized images that brought together disparate cultures and styles in an eclectic manner that mirrored the haphazard way that travel brought change to the Mediterranean world. My dissertation thus offers a more theoretically rigorous way of modeling culture change in antiquity that recognizes local communities’ agency in producing their cultural landscapes, reconciling some of the problems of scale that have plagued earlier approaches to provincial Roman art.

These case studies demonstrate that cultural anxieties played a key role in how viewers experienced artistic imagery in the Hellenistic and Roman Mediterranean. This dissertation thus offers a new component in our understanding of ancient visuality, and, in turn, a better way to analyze how local communities dealt with the rise of connectivity and globalization.

Institutions, Innovation, and Grassroots Change: Alternatives to Transnational Governance in the Global South

Transnational governance has been advanced as a viable option for regulating commodities produced in emerging economies—where incapable or unwilling states may undersupply institutions requisite for overseeing supply chains consistent with the quality, safety, environmental, or social standards demanded by the global marketplace. Producers from these jurisdictions, otherwise left with few venues for securing market access and price premiums, ostensibly benefit from whatever pathways transnational actors offer to minimize barriers to entry—including voluntary certification for compliance with a panoply of public and private rules, such as those promulgated by NGOs like the Fair Trade Federation or multinational retailers like Wal-Mart. Yet, such transnational “sustainability” governance may neither be effective nor desirable. Regulatory schemes, like third-party certification, often privilege the interests of primary architects and beneficiaries—private business associations, governments, NGOs, and consumers in the global North—over regulatory targets—producers in the global South. Rather than engaging with the international marketplace via imported and externally-driven schemes, some producer groups are instead challenging existing rules and innovating homegrown institutions. These alternatives to commercialization adopt some institutional characteristics of their transnational counterparts yet deliver benefits in a manner more aligned with the needs of producers. Drawing on original empirical cases from Nicaragua and Mexico, this dissertation examines the role of domestic institutional alternatives to transnational governance in enhancing market access, environmental quality and rural livelihoods within producer communities. Unlike the more technocratic and expert-driven approaches characteristic of mainstream governance efforts, these local regulatory institutions build upon the social capital, indigenous identity, “ancestral” knowledge, and human assets of producer communities as new sources of power and legitimacy in governing agricultural commodities.

Quantitative Analysis of Kilohertz-Frequency Neurostimulation

Mainstream electrical stimulation therapies, e.g., spinal cord stimulation (SCS) and deep brain stimulation, use pulse trains that are delivered at rates no higher than 200 Hz. In recent years, stimulation of nerve fibers using kilohertz-frequency (KHF) signals has received increased attention due to the potential to penetrate deeper in the tissue and to the ability to block conduction of action potentials. As well, there are a growing number of clinical applications that use KHF waveforms, including transcutaneous electrical stimulation (TES) for overactive bladder and SCS for chronic pain. However, there is a lack of fundamental understanding of the mechanisms of action of KHF stimulation. The goal of this research was to analyze quantitatively KHF neurostimulation.

We implemented a multilayer volume conductor model of TES including dispersion and capacitive effects, and we validated the model with in vitro measurements in a phantom constructed from dispersive materials. We quantified the effects of frequency on the distribution of potentials and fiber excitation. We also quantified the effects of a novel transdermal amplitude modulated signal (TAMS) consisting of a non-zero offset sinusoidal carrier modulated by a square-pulse train. The model revealed that high-frequency signals generated larger potentials at depth than did low frequencies, but this did not translate into lower stimulation thresholds. Both TAMS and conventional rectangular pulses activated more superficial fibers in addition to the deeper, target fibers, and at no frequency did we observe an inversion of the strength-distance relationship. In addition, we performed in vivo experiments and applied direct stimulation to the sciatic nerve of cats and rats. We measured electromyogram and compound action potential activity evoked by pulses, TAMS and modified versions of TAMS in which we varied the amplitude of the carrier. Nerve fiber activation using TAMS showed no difference with respect to activation with conventional pulse for carrier frequencies of 20 kHz and higher, regardless the size of the carrier. Therefore, TAMS with carrier frequencies >20 kHz does not offer any advantage over conventional pulses, even with larger amplitudes of the carrier, and this has implications for design of waveforms for efficient and effective TES.

We developed a double cable model of a dorsal column (DC) fiber to quantify the responses of DC fibers to a novel KHF-SCS signal. We validated the model using in vivo recordings of the strength-duration relationship and the recovery cycle of single DC fibers. We coupled the fiber model to a model of SCS in human and applied the KHF-SCS signal to quantify thresholds for activation and conduction block for different fiber diameters at different locations in the DCs. Activation and block thresholds increased sharply as the fibers were placed deeper in the DCs, and decreased for larger diameter fibers. Activation thresholds were > 5 mA in all cases and up to five times higher than for conventional (~ 50 Hz) SCS. For fibers exhibiting persistent activation, the degree of synchronization of the firing activity to the KHF-SCS signal, as quantified using the vector strength, was low for a broad amplitude range, and the dissimilarity between the activities in pairs of fibers, as quantified using the spike time distance, was high and decreased for more closely positioned fibers. Conduction block thresholds were higher than 30 mA for all fiber diameters at any depth and well above the amplitudes used clinically (0.5 – 5 mA). KHF-SCS appears to activate few, large, superficial fibers, and the activated fibers fire asynchronously to the stimulation signal and to other activated fibers.

The outcomes of this work contribute to the understanding of KHF neurostimulation by establishing the importance of the tissue filtering properties on the distribution of potentials, assessing quantitatively the impact of KHF stimulation on nerve fiber excitation, and developing and validating a detailed model of a DC fiber to characterize the effects of KHF stimulation on DC axons. The results have implications for design of waveforms for efficient and effective nerve fiber stimulation in the peripheral and central nervous system.