Journal articles on the topic 'New jersey, directories'

Background.In 2002, federal regulations authorized the use of standing orders programs (SOPs) for promoting influenza and pneumococcal vaccination. In 2003, the New Jersey Hospital Association conducted a demonstration project illustrating the efficacy of SOPs, and the state health department informed healthcare facilities of their benefits. We describe the prevalence of reported use of SOPs in New Jersey hospitals in 2003 and 2005 and identify hospital characteristics associated with the use of SOPs.Methods.A survey was mailed to the directors of infection control at 117 New Jersey hospitals during the period from January to May 2005 (response rate, 90.6%). Data on hospital characteristics were obtained from hospital directories and online resources.Results.The prevalence of use of SOPs for influenza vaccination was 50% (95% confidence interval [CI], 40.1%-59.9%) in 2003, and it increased to 78.3% (95% CI, 69.2%-85.7%) in 2005. The prevalence of SOP use for pneumococcal vaccination was similar. In 2005, the reported rate of use of SOPs for inpatients (influenza vaccination, 76.4%; pneumococcal vaccination, 75.5%) was significantly higher than that for outpatients (influenza vaccination, 9.4%; pneumococcal vaccination, 8.5%). Prevalence ratios for SOP use comparing acute care and non-acute care hospitals were 1.71 (95% CI, 1.2-2.5) for influenza vaccination SOPs and 1.8 for (95% CI, 1.2-2.7) pneumococcal vaccination SOPs. Acute care hospitals with a ratio of admissions to total beds greater than 36.7 reported greater use of SOPs for pneumococcal vaccination, compared with those that had a ratio of less than 36.7.Conclusion.The increase in the prevalence of reported use of SOPs among New Jersey hospitals in 2005, compared with 2003, was contemporaneous with SOP-related actions taken by the federal government, the state government, and the New Jersey Hospital Association. Opportunities persist for increased use of SOPs among non-acute care hospitals and for outpatients.

Korean immigrants in the United States (U.S.) are known for their preference for, and dependence on, co-ethnic doctors due to various barriers to the U.S. healthcare system. Recent immigrants tend to face more barriers than their non-recent counterparts. However, there is little information on how they find their doctors in the U.S. This study includes a self-administrated survey of Korean immigrants aged 18 and above who lived in the New York–New Jersey Metropolitan area in 2013–2014 (n = 440). Descriptive analysis was conducted to understand the most common information sources and the number of sources based on the duration of stay in the U.S. More recent Korean immigrants were female, had no family doctor, uninsured, younger, and more educated than their non-recent counterparts. Regardless of the duration of stay in the U.S., family members and friends were the most frequently sought-after sources for Korean immigrants in their search for doctors. In addition to family members and friends, non-recent Korean immigrants also used other methods (e.g., Korean business directories), whereas recent immigrants used both U.S. and Korean websites. More recent Korean immigrants used multiple sources compared to non-recent Korean immigrants, often combined with a Korean website. Our study suggests policy implications to improve recent immigrants’ accessibility to health information in a timely manner.

The distinction between a minor professional architect and a leading builder in Wellington was considerably more blurred in the late nineteenth century than it would be today. However, busy architects could make a lot of money and the term "architect" carried status that might open more doors than would be available to a mere builder. Late nineteenth century Wellington is now apparently only represented by a handful of buildings by prominent architects. Most people automatically think of the CBD and names like Thomas Turnbull & Son, William Chatfield, Frederick de Jersey Clere, John Campbell and perhaps William Crichton. Clayton, Toxward and Tringham were dead or almost gone, and new generation architects were barely emerging. We contend, however, that this picture is an oversimplification and considerably more of 1890s Wellington remains, as does the evidence for a much longer roll-call of architects, some of whom practised on the fringes, both of the city and of their profession. The architects we discuss here did not generally design large, flamboyant buildings, nor did they cater for rich company clients. Many of the lesser-known architects were particularly susceptible to boom-bust cycles and were forced to seek other employment in lean times - hence their rapid arrivals and departures from the trade listings in the directories of these years

This study examines the legal capacity available to low-income immigrants on national, state and sub-state levels. Legal professionals working in charitable immigration service programs serve as the study's rough proxy for legal capacity, and undocumented immigrants its proxy for legal need. The Center for Migration Studies of New York (CMS) compiled data on charitable immigration programs and their legal professionals from the: US Department of Justice's (DOJ's) “Recognized Organizations and Accredited Representatives Roster by State and City,” which is maintained by the Executive Office for Immigration Review's (EOIR's) Office of Legal Access Programs (OLAP). Directories of two leading, legal support agencies for charitable immigration legal programs, the Catholic Legal Immigration Network, Inc. (CLINIC) and the Immigrant Advocates Network (IAN). CMS supplemented and updated these sources with information from the websites of charitable immigration programs. It also added legal programs to its dataset that did not appear in any of these lists. It counted as legal professionals, attorneys, federally accredited non-attorneys, paralegals and legal assistants. The paper finds that there are 1,413 undocumented persons in the United States for every charitable legal professional, and far less capacity than the national average in: States such as Alabama (6,656 undocumented per legal professional), Hawaii (4,506), Kansas (3,010), Georgia (2,853), New Jersey (2,687), Florida (2,681), North Carolina (2,671), Virginia (2,634) and Arizona (2,561). Metropolitan areas (MAs) such as Riverside-San Bernardino-Ontario (5,307), Dallas-Fort Worth-Arlington (4,436), Phoenix-Mesa-Scottsdale (3,439) and Houston-The Woodlands-Sugar Land (3,099). San Bernardino County (6,178), Clark County (4,747), Riverside County (4,625), Tarrant County (3,955) and Dallas County (3,939). The study's introduction summarizes its top-line findings. Its first section describes the importance of charitable immigration legal programs to immigrants, families and communities. Its second details the study's findings on charitable legal capacity and immigrant need. Its third compares the legal capacity of 1,803 charitable legal programs and their 7,322 legal professionals, with the US undocumented population by state and for the 15 largest MAs and counties. Its fourth describes CMS's research methodology and data sources. The paper ends with policy recommendations on how to expand legal capacity for low-income immigrants and better assess legal capacity and need moving forward.

Purpose This research study aims to examine influences on the public library funding decision from the perspectives of New Jersey mayors and public library directors. Design/methodology/approach Content analysis was used to explore statements of 84 public library directors and 45 mayors about what was most/least effective in a recent library budget request. Findings Although they may differ on the relative importance of a specific concept, the public library directors and mayors in this study have high levels of agreement about what information is important in the budget decision process. Research limitations/implications The primary limitations of the findings of this study stem from the reliability of self-reported data and the low response rates. While the researcher believes that the findings and conclusions are valid for the survey respondents, it is less certain that they are valid for all public libraries in New Jersey, and it is not recommended that the conclusions be extended to public libraries outside of the state which differ in state mandates and other circumstances. Practical implications Understanding more about the factors that can influence library funding decisions provides insight into the very complex public library funding process and may help public library directors and mayors engage in mutually satisfactory budget negotiations. Originality/value This study contributes to the Library and Information Science research literature on library budgets by examining influences on the public library funding decision, specifically adding the perspectives of mayors and public library directors on a recent budget cycle.

Rising public interest in and use of holistic health (HH) practices and complementary and alternative medicine (CAM) has created a need for health care providers to become knowledgeable in these areas. HH/CAM content is increasingly included in curricula of professional health education, a trend less clear in associate, certificate, and diploma programs of 2-year colleges. A survey of directors and coordinators of allied health and nursing programs at New Jersey county colleges was conducted to determine curricular presence of HH/CAM and program constituency awareness of institutionally accessible HH/CAM information resources. Results indicated: rising interest in HH/CAM instruction; multiple forces influencing HH/CAM inclusion; HH/CAM strengthening programs; and uncertainty regarding knowledge of and perceived use of library HH/CAM resources. By including HH/CAM, New Jersey's allied health and nursing programs are progressively aligned with consumer use, and trends of professional health schools.

In October 1998 the Italian director Pino DiBuduo visited the Newark, New Jersey, campus of Rutgers University on the occasion of the major international conference, ‘Arts Transforming the Urban Environment’ For the occasion, he transformed a bleakly concrete teaching block on the Newark campus into a site for the latest of his Invisible Cities projects. These had originated in his Teatro Potlach company's residency in the Italian village of Fara Sabina in 1991, where DiBudo's intention – as in a number of site-specific variations on Invisible Cities since – was to render ‘visible’ aspects of the everyday urban environment which we no longer have the imagination or the patience to ‘see’. While Deborah Saivetz looks also at this original Italian project, and at a later version in Klagenfurt, Austria, she concentrates here on the Newark production, whose development she recorded – in this opening article in her own and DiBuduo's words, and in the following piece through the experiences and recollections of the participants. Deborah Saivetz holds a doctorate in Performance Studies from Northwestern University, and is currently Assistant Professor of Theater in the Department of Visual and Performing Arts at the Newark campus of Rutgers University. Her directorial work includes productions for the New Jersey Shakespeare Festival, the Drama League of New York's Directors’ Project, New York's Alchemy Courthouse Theater, and the Parallax Theater Company in Chicago. She has also worked with JoAnne Akalaitis as assistant director on John Ford's ‘Tis Pity She's a Whore at Chicago's Goodman Theatre, and created original theatre pieces with Chicago's Industrial Theater and Oxygen Jukebox.

There has long been recognition for improved education and training in aging and geriatrics. As the number of older individuals in the United States increases, with 20% being older than 65 years by 2030, it will become increasingly important for internists and medical subspecialty trainees to have proper training in the care of older adults. A survey was developed and administered to Internal Medicine Program Directors, to perform an educational needs assessment. The survey was administered during the beginning of the 2015 academic year via email. The survey assessed general program characteristics, details regarding required geriatric and palliative medicine teaching, opportunities for electives, barriers encountered at each training site, and future recommendations for improving the structure of resident education. Analysis of survey responses indicated that geriatric and palliative care education is lacking. Although all training programs provided some aspect of geriatric and palliative medicine training to internal medicine residents, only 27% of training programs had a formal curriculum in geriatric and palliative medicine. The majority had an informal curriculum. Very few programs reported using a multimodality approach; most used isolated experiences in either an inpatient or an outpatient setting. Although all residency directors believed curricular developments in geriatric and palliative medicine were important, very few have available faculty needed to facilitate curricular improvements. Almost all identified that they would use a restructured curriculum if it were readily available. Investment in developing content and a standardized curriculum in geriatric and palliative medicine would be very valuable and well received in New Jersey.

In the United States, the Commercial Sexual Exploitation of Children (CSEC) has been one of the principal foci in the fight against human trafficking during the past decade with billions of dollars spent and hundreds of thousands of helping professionals trained in anti-trafficking best practices. Despite this attention, prosecutions, convictions and rescues have been scarce relative to funding, leading critical scholars to argue that CSEC is a moral panic. The following article, based on fourteen months of participant-observation between 2009 and 2010 with social service providers, law enforcement officials, not-for-profit directors and local clergy from a voluntary participation federal anti-trafficking taskforce in Atlantic City, New Jersey provides an ethnographic account of the ways that helping professionals confront the challenges and contradictions of implementing policy and advocating for an invisible target population that is rarely, if ever, visible in their work lives.

Background: Blasts and leukemic stem cells of acute myeloid leukemia (AML) as well as several other hematologic malignancies express CD123, potentially providing a target for novel therapies. Vibecotamab (XmAb14045, SQZ622) is a potent bispecific antibody targeting both CD123 and CD3 that stimulates targeted T cell-mediated killing of CD123-expressing cells, regardless of T cell antigen specificity. It is a full-length immunoglobulin molecule designed to be dosed intermittently. Methods: Patients with relapsed or refractory AML, B-cell acute lymphoblastic leukemia (B-ALL), blast phase chronic myelogenous leukemia, or blastic plasmacytoid dendritic cell neoplasm were eligible to enroll on this first-in-human, multicenter, open-label phase 1 dose-escalation study (XmAb14045-01) with standard 3+3 design. The primary objective was to estimate the maximum tolerated dose (MTD) or recommended dose and schedule of vibecotamab. Secondary objectives included safety, preliminary antileukemic activity, and pharmacokinetics/pharmacodynamics of vibecotamab. Treatment was administered weekly in 28-day cycles, using a weight-based dose with 3 escalating doses in the first week followed by escalating weekly doses. Therapy was continued for as long as tolerated and there was continuing evidence of therapeutic benefit in the opinion of the investigator. Treatment response was assessed by the 2017 European LeukemiaNet (ELN) criteria after Cycle 1 and after each odd-numbered cycle. CRS was graded using the CRS revised grading system (Lee et al., Blood, 2014). Results: At data cut-off, 104 patients with AML, 1 with B-cell ALL, and 1 with CML as their primary diagnosis have been treated at dosages from 0.003 to 12.0 µg/kg vibecotamab. Patients had a median age of 63 years and were heavily pretreated (median of 3 prior therapies [range 1-8], including 32 (30%) who had undergone prior allogeneic stem cell transplantation). The recommended initial priming dose is 0.75 µg/kg; no MTD has been identified. CRS or its component symptoms was the most common treatment-emergent adverse event (TEAE). CRS occurred in 62 of 106 patients (85% grade 1-2, 15% grade ≥3), the majority on the first dose. Additional events consistent with CRS or infusion related reaction were seen in 24% of subjects (chills, fever, tachycardia, hypotension, etc.), and they were mostly mild or moderate severity. No myelosuppression requiring dose modification or evidence of tumor lysis syndrome was seen. Response of CR (2), CRi (3) or MLFS (2) was observed in 7/51 patients (ORR=14%) treated at higher dose levels (0.75 µg/kg). Stable Disease was observed in an additional 36 patients (71%). No CR, CRi, or morphologic leukemia-free state (MLFS) responses were observed at lower doses. Antileukemic activity occurred quickly; 6 out of 7 responders achieved at least a MLFS response after first cycle. A characterization of responders versus non-responders revealed responding patients harbor a lower burden of disease and specific T-cell subtypes. No association was found between response status and CD123 target expression on AML blasts. Conclusions: Vibecotamab demonstrated evidence of antileukemic activity in heavily pretreated patients with relapsed/refractory AML treated at the ≥0.75 µg/kg doses cohorts, with a 14% response rate. CRS was the most common toxicity but was generally manageable with premedications. The study is ongoing with further optimization of dose and schedule. Biomarker data suggest a population of AML patients that are more likely to respond. Additional information will be provided at the time of the meeting. Disclosures Ravandi: Celgene: Consultancy, Honoraria; BMS: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Orsenix: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria, Research Funding; Xencor: Consultancy, Honoraria, Research Funding; Jazz Pharmaceuticals: Consultancy, Honoraria, Research Funding; AstraZeneca: Consultancy, Honoraria; Macrogenics: Research Funding. Stock:Adaptive Biotechnologies: Consultancy, Membership on an entity's Board of Directors or advisory committees; Research to Practice: Honoraria; American Society of Hematology: Honoraria; Leukemia and Lymphoma Society: Research Funding; Novartis: Research Funding; Abbvie: Honoraria, Research Funding; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Morphosys: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kite: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Servier: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; UpToDate: Honoraria. Foran:Xencor: Research Funding; H3Biosciences: Research Funding; Agios: Honoraria, Research Funding; Trillium: Research Funding; Takeda: Research Funding; Kura Oncology: Research Funding; Aptose: Research Funding; Aprea: Research Funding; Actinium: Research Funding; Boehringer Ingelheim: Research Funding; Abbvie: Research Funding; BMS: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Revolution Medicine: Consultancy. Mawad:Adaptive Biotechnologies: Speakers Bureau; Abbvie: Speakers Bureau. Blum:Celyad: Research Funding; Amerisource Bergen: Honoraria; Syndax: Membership on an entity's Board of Directors or advisory committees; Leukemia and Lymphoma Society: Research Funding; Xencor: Research Funding. Yang:Xencor: Current Employment, Current equity holder in publicly-traded company; Jazz Pharmaceuticals: Current equity holder in publicly-traded company, Ended employment in the past 24 months. Pastore:Novartis NIBR East Hanover New Jersey: Current Employment, Current equity holder in publicly-traded company; Memorial Sloan Kettering Cancer Center: Ended employment in the past 24 months. Johnson:Xencor: Current Employment, Current equity holder in publicly-traded company. Zheng:Xencor: Current Employment, Current equity holder in publicly-traded company; Tocagen: Ended employment in the past 24 months. Yilmaz:Pint Pharma: Honoraria; Pfizer: Research Funding; Daicho Sankyo: Research Funding. Mims:Syndax Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Kura Oncology: Membership on an entity's Board of Directors or advisory committees; Leukemia and Lymphoma Society: Other: Senior Medical Director for Beat AML Study; Jazz Pharmaceuticals: Other: Data Safety Monitoring Board; Agios: Consultancy; Novartis: Speakers Bureau.

Abstract INTRODUCTION : Leukemia is the seventh leading cause of cancer death in the United States (US) in 2021. The Mortality Incidence Rate Ratio, also known as Mortality-to-Incidence Ratio (MIR), is calculated by dividing the mortality rate by the incidence rate for selected cancers and population. The MIR provides a population-based indicator of cancer survival which has previously been used to assess healthcare disparities among different countries. Here weevaluated the potential association between leukemia MIR and state-based health disparities in the US. METHODS: Leukemia (AML, CML, ALL, CLL and other leukemias) MIRs for 2008-2017 were obtained from United States Cancer Statistics (USCS) database provided by the Centers for Disease Control and Prevention (CDC). America's Health Rankings (AHR), a partnership of the United Health Foundation and the American Public Health Association, evaluates the nation's health on a state-by-state basis by using weighted measures in 5 different categories (25% for Behaviors, 22.5% for Community & Environment, 12.5% for Policy, 15% for Clinical Care, and 25% for Outcomes). AHR then determines state health rankings and reflects state health disparities based on these specific factors. Here we analyzed the potential association between leukemia MIRs and state health rankings by linear regression. RESULTS: From 2008 to 2017, a total of 489,037 people were diagnosed with leukemia and 231,069 people died from leukemia in the US. The 10-year average of age-adjusted incidence rate and mortality rate were 14.2 and 6.7 per 100,000 population respectively. The average MIR between all states was calculated to be 0.470. As seen in Table 1, the lowest MIR (best survival) was found in Florida (0.374), New York (0.391), and New Jersey (0.412) with AHR 34, 19 and 11 respectively. The highest MIR (worst survival) was found in Mississippi (0.579), Wyoming (0.570), and Ohio (0.569) with AHR 50, 24 and 37 respectively. According to AHR, over the last decade, the states with the highest health rankings were reported in Vermont (No. 1), Hawaii (No. 2), and Massachusetts (No. 3) with MIR 0.508, 0.439 and 0.502 respectively. The states with the lowest health rankings were reported in Arkansas (No. 48), Louisiana (No. 49), and Mississippi (No. 50) with MIR 0.559, 0.503 and 0.579 respectively. In our analysis, states with better health rankings were significantly associated with lower MIRs (R 2=0.232, P<0.001), as seen in Figure 1. CONCLUSIONS: There is a remarkable geographic difference in leukemia MIRs in the US between 2008-2017. Leukemia MIR was significantly associated with state health rankings reported by the AHR. Although the quality of clinical care for leukemia patients remains to be an important predictor of mortality, our findings suggest that other aggregate determinants of health, including social, economic, and community and physical environment may also play a vital role in influencing leukemia survival. More in-depth analysis of these data focusing on specific leukemia subtypes as well as other factors (race, gender, age) may be helpful in identifying and addressing other non-medical issues negativity impacting on leukemia outcomes in different geographical regions in the United States. Figure 1 Figure 1. Disclosures Wang: Kura Oncology: Consultancy, Honoraria, Other: Advisory board, steering committee, Speakers Bureau; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Stemline Therapeutics: Consultancy, Honoraria, Other: Advisory board, Speakers Bureau; Kite Pharmaceuticals: Consultancy, Honoraria, Other: Advisory Board; Takeda: Consultancy, Honoraria, Other: Advisory board; Pfizer: Consultancy, Honoraria, Other: Advisory Board, Speakers Bureau; Novartis: Consultancy, Honoraria, Other: Advisory Board; Mana Therapeutics: Consultancy, Honoraria; BMS/Celgene: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Consultancy, Honoraria, Other: Advisory Board; Jazz Pharmaceuticals: Consultancy, Honoraria, Other: Advisory Board; DAVA Oncology: Consultancy, Speakers Bureau; Rafael Pharmaceuticals: Other: Data safety monitoring committee; Gilead: Consultancy, Honoraria, Other: Advisory board; Daiichi Sankyo: Consultancy, Honoraria, Other: Advisory board; PTC Therapeutics: Consultancy, Honoraria, Other: Advisory board; Genentech: Consultancy; MacroGenics: Consultancy.

Abstract Background: The American College of Chest Physicians (ACCP) guidelines for venous thromboembolism (VTE) disease recommend treatment with anticoagulation for at least 3 months in patients with VTE. Moreover, the EINSTEIN-extension study assessed the effect of rivaroxaban on the risk of VTE recurrences in patients who had completed 6 to 12 months of treatment for VTE. Results showed that rivaroxaban significantly reduced the risk of VTE recurrences with a small increased risk of major bleeding. The objective of this study was to assess the risk of VTE recurrences and major bleeding associated with extended rivaroxaban treatment in a real-world setting among all VTE patients (i.e., unprovoked, provoked, and cancer related). Methods: A retrospective study was conducted using Truven Health Analytics MarketScan Databases from 02/2011 to 04/2015. The study included adult patients who initiated rivaroxaban therapy within 7 days after their first VTE and continuously used rivaroxaban for at least 3 months. The end of the initial 3-month rivaroxaban treatment was defined as the index date and patients were categorized into discontinued (treatment ended) and continued cohorts. Patients were followed from index date until end of continuous treatment for the continued cohort or end of data or re-initiation of oral anticoagulant therapy for the discontinued cohort. The outcomes included VTE recurrences identified as a primary diagnosis documented during a hospitalization and major bleeding events identified by a validated algorithm (Cunningham et al., 2011). Kaplan-Meier rates for VTE recurrences and major bleeding events at 3, 6, 9, and 12 months after the index date were compared between cohorts with adjustment for baseline confounding using the inverse probability of treatment weights (IPTW) method based on propensity score. Patients with unprovoked VTEs, defined as not having recent surgery, cancer, pregnancy or estrogen therapy, were also evaluated. Sample sizes of patients with provoked VTEs and cancer were too small to analyze these populations. A sensitivity analysis was also conducted among VTE patients receiving rivaroxaban for at least 6 months. Results: Among the 3-month treatment population, a total of 5,933 (63.4% unprovoked VTE) and 1,536 (68.4% unprovoked VTE) rivaroxaban users formed the continued and discontinued cohorts, respectively. The mean (SD) observation period was 149.3 (124.4) days in the continued cohort and 211.1 (191.6) days in the discontinued cohort. The Kaplan-Meier analysis (Figure 1) showed that patients in the continued cohort had significantly lower rates of VTE recurrences after an additional 3 months (0.70% vs. 1.70%), 6 months (1.41% vs. 2.34%), 9 months (1.82% vs. 3.01%), and 12 months (1.97% vs. 3.01%; all p-values < 0.05) of treatment. No statistically significant differences in the cumulative event rates for major bleeding (Figure 2) were observed between the continued and the discontinued cohort at 3 months (0.58% vs. 0.82%), 6 months (0.91% vs. 0.88%), 9 months (1.33% vs. 1.18%), and 12 months (1.44% vs. 1.44%; all p-values > 0.05). Among the 6-month treatment population, a total of 2,676 (65.9% unprovoked VTE) and 1,127 (70.4% unprovoked VTE) rivaroxaban users formed the continued and discontinued cohorts, respectively. The mean (SD) observation period was 158.5 (130.6) days in the continued cohort and 206.5 (171.5) days in the discontinued cohort. Patients in the continued cohort had lower rates of VTE recurrences after an additional 3 months (0.82% vs. 1.41%), 6 months (1.22% vs. 2.69%), 9 months (1.35% vs. 3.02%), and 12 months (1.72% vs. 3.70%; except at 3 months all p-values < 0.05) of treatment. No differences in the cumulative event rates for major bleeding were observed between the continued and the discontinued cohorts. Similar results were found among patients with unprovoked VTE for the 3- and 6-month analyses. The interaction term between the cohort variable (Continued vs. Discontinued) and the type of VTE (unprovoked vs. other types of VTE) was non-significant in both populations (p-value > 0.05), which suggests that the benefit of extended treatment do not depend on the type of VTE events. Conclusions: Our study results suggest that all patients with VTE who continued rivaroxaban therapy after the first 3-month and 6-month treatment periods had significantly lower risk of VTE recurrences without an increased risk of major bleeding. Disclosures Khorana: Halozyme: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding; Leo: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Janssen Scientific Affairs, LLC: Consultancy, Honoraria, Research Funding. Berger:AZ: Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees. Wells:BMS/Pfizer: Research Funding; Itreas: Other: Served on a Writing Committee; Janssen Pharmaceuticals: Consultancy; Bayer Healthcare: Other: Speaker Fees and Advisory Board. Seheult:Janssen Scientific Affairs, LLC: Consultancy. Ashton:Janssen Scientific Affairs, LLC, Raritan, New Jersey: Employment. Laliberté:Janssen Scientific Affairs: Research Funding. Crivera:Janssen Scientific Affairs, LLC, Raritan, New Jersey: Employment, Equity Ownership. Lejeune:Janssen Scientific Affairs: Research Funding. Schein:Johnson & Johnson: Employment, Equity Ownership, Other: Own in excess of $10,000 of J&J stock. Wildgoose:Janssen Scientific Affairs, LLC, Raritan, New Jersey: Employment, Equity Ownership. Lefebvre:Janssen Scientific Affairs: Research Funding. Kaatz:Bristol Myer Squibb: Honoraria; Pfizer: Honoraria; CSL Behring: Honoraria; Boehringer Ingelheim: Consultancy; Pfizer: Consultancy; Janssen: Consultancy; Daiichi Sankyo: Consultancy; Bristol-Myers Squibb: Consultancy; Boehringer Ingelheim: Honoraria; Janssen: Honoraria.

Abstract Background: Peripheral T-Cell lymphomas (PTCL) are an uncommon, heterogeneous group of disorders that are difficult to treat due a lack of a consensus standard of care algorithms. Conventional B-cell lymphoma chemotherapy regimens have been adapted for use in PTCL but have shown low response rates, short durations of response and generally poor outcomes. Mature T/NK cell lymphoma-specific therapies are now available, however their sequencing into treatment algorithms is not defined. The objective of this study was to determine which regimens are currently being used and the associated outcomes for PTCL patients (pts) in community settings. Patients & methods: A retrospective review was performed of newly diagnosed and relapsed/refractory pts with PTCL, including anaplastic large cell lymphoma (ALCL), PTCL not otherwise specified (NOS), and angioimmunoblastic T-cell lymphoma (AITL) treated by Regional Cancer Care Associates between January 1, 2010 and April 30, 2015. Pts were identified using the COTA software platform, which extracts data from electronic health records and permits real-time observational database analysis. Results: 93 pts with ALCL (n=30), PTCL-NOS (n=44), or AITL (n=19) treated by 30 physicians throughout New Jersey were identified. Median age at diagnosis was 61 (range: 19-91), with ALCL pts younger than other subtypes (53 years, 65 years, 62 years, respectively). Pts were predominantly male (63%). 55 pts (81% of assessed pts) had an Ann Arbor stage of III/IV and 34 pts (41% of assessed pts) had an international prognostic index (IPI) score >3. ALK positivity was identified in 40% of assessed ALCL pts. Median time to the 1st oncology visit from pathologic diagnosis was 29 days; time to treatment initiation was 15 days later. The analysis demonstrated significant variation in the treatment of newly diagnosed pts. As initial 1st line therapy, there were 13 different regimens used among 21 pts with ALCL, 18 different regimens among 29 pts with PTCL-NOS, and 7 regimens used in the 16 pts with AITL. CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) was the most frequently prescribed 1st line chemotherapy regimen, used by 37 pts (56%) and an additional 12 pts (18%) were prescribed a CHOP-like regimen. The complete response rates and duration of response for first line CHOP plus CHOP-like regimens (excluding pts consolidated by transplant n=38) was 39% / 33.7 months for all PTCL subtypes (75% CR/37.8 months for ALCL, 24% CR/26.5 months for PTCL-NOS, and 22%CR/36.9 months for AITL). The 4-year PFS and OS for these 1st line CHOP/CHOP-like pts was 50% and 50% respectively. Transplants were performed as part of initial therapy in 12 pts (2 allo; 10 auto) with a 4-year PFS 57% and 4-year OS 55% (p=0.29 and p=0.63; log-rank, compared to CHOP without BMT). Relapsed/refractory PTCL show similar variability in treatment regimens. There were 7 different salvage regimens for the 7 ALCL pts, 15 different regimens for the 15 PTCL-NOS pts, and 5 different regimens for the 5 AITL pts. Across all patient types there were 29 unique regimens used to treat relapsed/refractory PTCL pts. Romidepsin monotherapy (n=6) and brentuximab monotherapy (n=6) were the most common regimens. Salvage transplants were performed in 6 pts (3 allo & 3 auto). From date of diagnosis ALCL (ALK positive) pts had a 4-year PFS 68% and an OS at 4-years 100%. ALCL (ALK negative) pts had a 4-year PFS of 73% and an OS 80%. PTCL-NOS pts had a 4-year PFS of 32% and OS 42% (median PFS 13 months and a median OS 30 months). AITL pts had a 4-year PFS 48% and OS 42% (median PFS 12 months and a median OS 25 months). Conclusion: This retrospective review demonstrated significant variability in the regimens used to treat PTCL pts outside of protocol settings. Although CHOP / CHOP-like therapy was the most common initial therapy (used in 74% of pts) with transplant up-front consolidation in 12 pts (26%), there appears to be no consensus on the optimal management approach for the PTCL subtypes and in each line of therapy. No benefit was noted in our series for upfront transplant. The survival outcomes in this community based cohort are comparable with recent multi-center institutional studies (COMPLETE and Abramson et al) and demonstrate improving survival for AITL pts versus historical control. There is a need to assess the comparative effectiveness of available treatment options in these diseases to better inform future treatment decisions. Disclosures Feldman: Celgene: Honoraria, Speakers Bureau; Pharmacyclics/JNJ: Honoraria, Speakers Bureau; Seattle Genetics: Honoraria, Speakers Bureau. McGuire:Celgene: Employment. Faria:Celgene: Employment. Goy:Pharmacyclics/JNJ: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Acerta: Membership on an entity's Board of Directors or advisory committees. Farber:Jansen Pharmacyclics: Honoraria, Speakers Bureau; Gilead Sciences: Speakers Bureau; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Genentech: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Choi:COTA: Employment. Connors:COTA: Employment. Paramanathan:COTA: Employment. Schultz:COTA: Employment. Goldberg:Ariad: Research Funding, Speakers Bureau; COTA: Employment, Equity Ownership, Other: Leadership, Stock; Novartis: Research Funding, Speakers Bureau; BMS: Research Funding, Speakers Bureau; Pfizer: Research Funding.

Abstract Introduction: Patients with cancer are not only at a high risk for developing primary but also recurrent venous thromboembolism (VTE). These events lead to increased burden of cancer management and healthcare costs. It was estimated that all-cause health care costs for cancer patients with VTE were $30,538/patient higher than in those without VTE (Khorana, 2013). To our knowledge, very little information exists on cost of VTE recurrence among cancer patients. The objective of this study was to analyze resource utilization and costs of patients with cancer experiencing a VTE recurrence using a large claims database. Methods: Medical and pharmacy claims from the Humana Database between 1/1/2013 and 05/31/2015 were analyzed. Newly diagnosed cancer patients with a first VTE diagnosis occurring after their first cancer diagnosis and with ≥1 dispensing of an anticoagulant agent within 7 days after their VTE diagnosis, were selected. Baseline characteristics were evaluated during the 6 month period prior to the index VTE. VTE recurrences were defined as hospitalizations with a primary diagnosis of VTE. Patients were classified into two groups: patients who experienced a VTE recurrence and patients who did not. Resource utilization and costs were evaluated for the entire follow up period, starting with the initiation of the anticoagulant therapy until whichever was earlier, end of eligibility or end of data. Healthcare resource utilization evaluated included number of hospitalizations, hospitalization days, emergency room (ER) visits, and outpatient visits. All-cause and VTE-related healthcare resource utilization was evaluated. Comparisons between patients with a VTE recurrence and patients without a VTE recurrence were performed using rate ratios (RR) and statistical differences between groups as well as 95% confidence intervals [95% CI] were calculated using Poisson regression models. All-cause and VTE-related healthcare costs were evaluated in per-patient-per-year (PPPY) and compared using mean cost difference. Results: A total of 2,428 newly diagnosed cancer patients who developed VTE and were treated with anticoagulants were identified. Of these, 413 (17.1%) experienced recurrent VTE during the follow up period. Patients who developed recurrent VTE and those who did not were similar in terms of age, gender, race, and region. No statistically significant differences between groups were observed in Charlson comorbidity index or in selected comorbidities during the 6 month baseline period. However, more patients with recurrent VTE recurrence had their index VTE documented during a hospitalization (61.3% vs. 55.4%, p=0.03). Patients with a VTE recurrence had significantly more ER and outpatient visits at baseline compared to those without recurrence, but no statistically significant difference was observed in baseline total healthcare costs ($29,352 vs. $27,955, p=0.44, respectively). The mean follow-up was similar between groups: 9.6 months for patients experiencing a VTE recurrence and 9.3 months for patients without a VTE recurrence (p=0.4059). Patients with a VTE recurrence had higher all-cause resource utilization rates (RRs; 95% CI) compared to patients without a VTE recurrence (hospitalization [2.37; 2.23 - 2.52], hospitalization days [2.64; 2.57 - 2.72], ER visits [1.62; 1.48 - 1.76], and outpatient visits [1.26; 1.24 - 1.28]). The rates of VTE-related hospitalization and VTE-related hospitalization days were close to $30,000 higher in patients with a VTE recurrence (Figure 1). The all-cause healthcare costs were $84,708 PPPY in patients with a VTE recurrence compared to $44,903 in patients without a VTE recurrence. The difference was mainly explained by lower VTE-related hospitalization costs (Figure 2). Conclusion: This real-world claims analysis showed that cancer patients with recurrent VTE consume significantly more healthcare resources. Total healthcare costs were nearly 2-fold higher in cohort with than in cohort without VTE recurrence. Close to 75% of the total cost difference was associated with VTE recurrence. VTE-related costs were ~4-fold higher in cohort with than in cohort without VTE recurrence. Reducing VTE recurrence in patients with cancer could lead to substantial healthcare cost savings. Figure 1 VTE-Related Healthcare Resource Utilization Figure 1. VTE-Related Healthcare Resource Utilization Figure 2 VTE-Related Healthcare Costs, PPPY Figure 2. VTE-Related Healthcare Costs, PPPY Disclosures Khorana: Pfizer: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Halozyme: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding; Janssen Scientific Affairs, LLC: Consultancy, Honoraria, Research Funding; Leo: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria. McCrae:Janssen: Membership on an entity's Board of Directors or advisory committees. Milentijevic:Janssen Scientific Affairs: Employment, Equity Ownership. Fortier:Janssen Pharmaceuticals: Research Funding. Laliberté:Janssen Scientific Affairs: Research Funding. Crivera:Janssen Scientific Affairs, LLC, Raritan, New Jersey: Employment, Equity Ownership. Lefebvre:Janssen Scientific Affairs: Research Funding. Schein:Johnson & Johnson: Employment, Equity Ownership, Other: Own in excess of $10,000 of J&J stock.

Abstract Introduction: Anticoagulation is effective for the treatment of venous thromboembolism (VTE) in cancer patients, but it is also associated with an increased risk of bleeding. Previous clinical trials (e.g., CLOT and CATCH) of LMWH and warfarin for the treatment of VTE in cancer patients reported major bleeding in 3% to 6% of treated patients. The objective of this observational study was to compare the risk of major bleeding in cancer patients treated with anticoagulants for VTE in a real world setting. Methods: Medical and pharmacy claims from the Humana Database from 1/1/2013 to 05/31/2015 were analyzed. Newly diagnosed cancer patients with a first VTE diagnosis occurring after their first cancer diagnosis, and with ≥1 dispensing of an anticoagulant within 7 days after their VTE diagnosis, were selected. Based on the first anticoagulant received, patients were classified into one of the following cohorts: LMWH, warfarin, and rivaroxaban (other agents not included due to low utilization). Inverse probability of treatment weights based on propensity score were used to adjust for differences between treatment cohorts for the following comparisons: LMWH vs. rivaroxaban, LMWH vs. warfarin, and rivaroxaban vs. warfarin. Patients were followed up until the earliest event, either treatment non-persistence (gap > 60 days between the end of the days of supply of a dispensing and the start date of the next dispensing), or end of data availability. Major bleeding events were identified using validated criteria (Cunningham et al., 2011). Kaplan-Meier rates at 3 and 6 months and Cox proportional hazards models were used to compare the risk of bleeding between different treatment cohorts. To better understand the risk of major bleeding in cancer patients unrelated to anticoagulation, a cohort of patients with cancer who did not have VTE and did not receive an anticoagulant was added as a control cohort. Results: A total of 2,428 patients (LMWH: n=660; warfarin: n=1,061; rivaroxaban: n=707) were included. Baseline demographic and clinical characteristics were well balanced among treatment cohorts. Median duration of therapy with LMWH was shorter than rivaroxaban (1.0 vs. 3.0 months, p<.0001) and warfarin (1.0 vs. 3.5 months, p<.0001). Rates of major bleeding for LMWH and rivaroxaban were 8.3% and 8.2%, respectively at 6 months with a hazard ratio (HRs [95% CI]) of 1.03 (0.64-1.65; Figure 1A). In the comparison between LMWH and warfarin cohorts, major bleeding rates were 8.5% and 8.6%, respectively at 6 months with hazard ratio (HRs [95% CI]) of 1.04 (0.69-1.57; Figure 1B). The risk of major bleeding was also similar for rivaroxaban and warfarin cohorts, 9.0% and 8.7%, respectively at 6 months with a hazard ratio (HR [95% CI]) of 1.01 (0.71-1.43; Figure 1C). For the control cohort of cancer patients without VTE and not receiving anticoagulation median follow-up was 5.6 months. Rates of major bleeding events for the control cohort were 2.6% and 4.2 % at 3 and 6 months, respectively. Conclusion: This real world study of cancer patients treated for VTE found that the risk of major bleeding was similar for the 3 most widely prescribed anticoagulants in current clinical practice: LMWH, warfarin, and rivaroxaban. The observed rates of major bleeding were generally higher than what has been reported for LMWH and warfarin in the CLOT and CATCH trials. Patient characteristics such as older age (average age 73 years) could have contributed to the higher major bleeding rate seen in this study compared to the CLOT and CATCH trials, respectively. Figure 1 Rates of Major Bleeding Events LMWH vs. rivaroxaban cohorts Figure 1. Rates of Major Bleeding Events. / LMWH vs. rivaroxaban cohorts Figure 2 LMWH vs. warfarin cohorts Figure 2. LMWH vs. warfarin cohorts Figure 3 rivaroxaban vs. warfarin cohorts Figure 3. rivaroxaban vs. warfarin cohorts Disclosures Streiff: Portola: Research Funding; Janssen: Consultancy, Research Funding; Roche: Research Funding; CSL Behring: Consultancy, Research Funding. Milentijevic:Janssen Scientific Affairs: Employment, Equity Ownership. McCrae:Janssen: Membership on an entity's Board of Directors or advisory committees. Yannicelli:Janssen Scientific Affairs: Employment, Equity Ownership. Fortier:Janssen Pharmaceuticals: Research Funding. Nelson:Janssen Scientific Affairs: Employment, Equity Ownership. Laliberté:Janssen Scientific Affairs: Research Funding. Crivera:Janssen Scientific Affairs, LLC, Raritan, New Jersey: Employment, Equity Ownership. Lefebvre:Janssen Scientific Affairs: Research Funding. Schein:Johnson & Johnson: Employment, Equity Ownership, Other: Own in excess of $10,000 of J&J stock. Khorana:Roche: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Halozyme: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Leo: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Janssen Scientific Affairs, LLC: Consultancy, Honoraria, Research Funding.

En las organizaciones se presentan varias debilidades vulnerables en los sistemas de control interno y en la manera en que las empresas gestionan su liquidez, de modo, que el control interno debe garantizar la efectividad de los objetivos económicos empresariales. El objetivo de este trabajo es analizar el constructo teórico del control interno mediante el modelo COSO, a través de un análisis meta-analítico. Adicionalmente, se aplicó la técnica estadística de meta-análisis, con el fin de evaluar el nivel de significancia y su sesgo de error, por tal razón se direccionó bajo un diseño metodológico mixto. Los resultados revelaron que el factor ambiente de control, es descuidado por parte de las organizaciones debido al empirismo que maneja el directorio administrativo de las pequeñas y medianas empresas. Se concluye que el modelo COSO, si mantiene relación consistente con el control interno y la gestión de liquidez empresarial. Palabras Clave: control interno, liquidez, gestión empresarial. Referencias [1]A. I. Calderón Peña y K. J. Jáuregui Salcedo, «El control interno y su relación con el cumplimiento de las obligaciones tributarias en las empresas comerciales,Chaclacayo, 2015,» Revista de Investigación Universitaria, vol. 5, nº 1, pp. 32-27, 2016. [2]H. Almeida, M. Campello, I. Cunha y M. S. Weisbach, «Corporate Liquidity Management: A conceptual Framework and Survey» El Annual Review of FinancialEconomics, vol. 6, pp. 135-162, 2014. [3]R. M. Cedeño Zambrano y L. M. Morell González, La gestión de riesgos en Ecuador: una aproximaciónevolutiva desde el control interno,» Cofín Habana., vol.12, nº 2, pp. 306-318, 2018. [4]M. P. Suntasig Tigse, El control interno del proceso de concesión de créditos y cobranzasy su incidencia en la liquidez de la empresa cereales La Pradera de la parroquia Belisario Quevedo, en el primer trimestre del año 2014, Latacunga: Universidad Técnica de Cotopaxi, 2014. [5]L. Graham, Internal Control Audit and Compliance, Canadá: JohnWiley & Sons, Inc., Hoboken, New Jersey. Published, 2015. [6]S. Mantilla, Auditoría del control interno (3a. ed.), México: ECOE, 2013. [7]N. Viloria, «Factores que inciden en el sistema de control interno de una organización.,» Actualidad Contable Faces, vol. 8, nº 11, pp. 87-92, 2005. [8]M. Samuel, Internal Control- Integrated Framework.,México: ECOE, 2008. [9]R. Estupiñán Gaitán, Administración de riesgos E.R.M. y la auditoría interna, 2006. [10]G. Rivas Márquez, «Modelos contemporáneos de control interno. Fundamentos teóricos,» Observatorio Laboral Revista Venezolana, vol. 4, nº 8, pp. 115-136, 2011. [11]S. A. Mantilla B, Control Interno Informe COSO, 2017. [12]L. R. Sánchez Sánchez, «COSO ERM y la Gestión de Riesgos.,» QUIPUKAMAYOC Revista de la Facultad de Ciencias Contables, vol. 23, nº 44, pp. 43-50, 2015. [13]M. E. Vivanco Vergara, «Los manuales de procedimientos como herramientas de control interno de una organización,» vol. 9, pp. 313-318, 2017. [14]A. L. Quispe Otoma, M. P. Padilla Matínez y J. A. Telot, «Tecnologías de información y comunicación en la gestión empresarial de pymes comerciales,» vol. XXXVIII, nº 1, pp. 81-92, 2017. [15]I. Domínguez García, «Evolución de la teoría sobre el análisis y gestión de la liquidez empresarial,» vol. 9, nº 1, pp. 66-80, 2015. [16]L. Gitman y C. Zutter, Prinpios de administración financiera, México, 2012. [17]F. Madrigal, S. Ayala y L. Chávez, «Análisis e interpretaciónde estados financieros en condiciones de incertidumbre,» vol. 2, p. 380, 2015. [18]J. Sánchez, «Cómo realizar una revisión sistemática y un meta-análisis,» Aula abierta, vol. 38, nº 2, pp. 53-64, 2010. [19]D. Ojeda y J. Wurth, «Qué es un Meta análisis ?,»Revista Chilena de Anestesía, nº 43, pp. 343-350, 2014. [20]J. A. González, E. Cobo y M. Villaró, «Revisión sistemática y meta-análisis,» Bioestadistica para no estadísticos, pp. 1-42, 2014. [21]E. Osadchy y E. M. Akhmetshin, «Development of the financial control system in the company in crisis,» Mediterranean Journal of Social Sciences, vol. 6, nº552, pp. 390-398, 2015. [22]I. C. Asubadin Azubadin, Control interno del Proceso de compras y su incidencia en la liquidez de la empresa comercial Yucailla Cia. Ltda. Latacunga durante el año 2010”, Latacunga: Universidad Técnica de Ambato, 2011. [23]J. C. Viera Quishpe, Diseño de un sistema de control interno administrativo y contable para el laboratorio autoservicio diésel de la sierra, ubicado en la ciudad de Latacunga, Latacunga: Universidad Central del Ecuador, 2015. [24]M. Nava Rosillón, «Análisis financiero: una herramienta clave para una gestión financiera eficiente.,» Revista Venezolana de Gerencia, vol. 14, nº 48, pp. 606-628, 2009. [25]S. P. Guayaquil Villarroel, El control interno y la razonabilidad de la información financiera en el Centro Comercial Popular de la ciudad de Latacunga en los locales comerciales de calzado en el período Enero - Junio 2016, Latacunga: Universidad Técnica de Ambato, 2015. [26]A. Masli, G. E. Peters, V. J. Richardson y J. Sanchez, «Examining the potential benefits of internal control monitoring technology, » Accounting Review, vol.85, nº 3, pp. 1001-1034, 2010. [27]D. C. Chasi Toca, “Gestión de riesgos y su incidencia en el control interno en el departamento financiero de la florícola fegacón cía. Ltda. Parroquia Joseguango bajo, cantón Latacunga, provincia de Cotopaxi”, Latacunga: Universidad Técnica De Cotopaxi Facultad, 2017.

Cultural sociologists (Bourdieu; DiMaggio, “Cultural Capital”, “Classification”; Gans; Lamont & Foumier; Halle; Erickson) wrote about high culture and popular culture in an attempt to explain the growing social and economic inequalities, to find consensus on culture hierarchies, and to analyze cultural complexities. Halle states that this categorisation of culture into “high culture” and “popular culture” underlined most of the debate on culture in the last fifty years. Gans contends that both high culture and popular culture are stereotypes, public forms of culture or taste cultures, each sharing “common aesthetic values and standards of tastes” (8). However, this article is not concerned with these categorisations, or macro analysis. Rather, it is a reflection piece that inquires if opera, which is usually considered high culture, has become more equal to popular culture, and why some directors change the time and place of opera plots, whereas others will stay true to the original setting of the story. I do not consider these productions “adaptations,” but “post-modern morphologies,” and I will refer to this later in the paper. In other words, the paper is seeking to explain a social phenomenon and explore the underlying motives by quoting interviews with directors. The word ‘opera’ is defined in Elson’s Music Dictionary as: “a form of musical composition evolved shortly before 1600, by some enthusiastic Florentine amateurs who sought to bring back the Greek plays to the modern stage” (189). Hence, it was an experimentation to revive Greek music and drama believed to be the ideal way to express emotions (Grout 186). It is difficult to pinpoint the exact moment when stage directors started changing the time and place of the original settings of operas. The practice became more common after World War II, and Peter Brook’s Covent Garden productions of Boris Godunov (1948) and Salome (1949) are considered the prototypes of this practice (Sutcliffe 19-20). Richard Wagner’s grandsons, the brothers Wieland and Wolfgang Wagner are cited in the music literature as using technology and modern innovations in staging and design beginning in the early 1950s. Brief Background into the History of Opera Grout contends that opera began as an attempt to heighten the dramatic expression of language by intensifying the natural accents of speech through melody supported by simple harmony. In the late 1590s, the Italian composer Jacopo Peri wrote what is considered to be the first opera, but most of it has been lost. The first surviving complete opera is Euridice, a version of the Orpheus myth that Peri and Giulio Caccini jointly set to music in 1600. The first composer to understand the possibilities inherent in this new musical form was Claudio Monteverdi, who in 1607 wrote Orfeo. Although it was based on the same story as Euridice, it was expanded to a full five acts. Early opera was meant for small, private audiences, usually at court; hence it began as an elitist genre. After thirty years of being private, in 1637, opera went public with the opening of the first public opera house, Teatro di San Cassiano, in Venice, and the genre quickly became popular. Indeed, Monteverdi wrote his last two operas, Il ritorno d’Ulisse in patria and L’incoronazione di Poppea for the Venetian public, thereby leading the transition from the Italian courts to the ‘public’. Both operas are still performed today. Poppea was the first opera to be based on a historical rather than a mythological or allegorical subject. Sutcliffe argues that opera became popular because it was a new mixture of means: new words, new music, new methods of performance. He states, “operatic fashion through history may be a desire for novelty, new formulas displacing old” (65). By the end of the 17th century, Venice alone had ten opera houses that had produced more than 350 operas. Wealthy families purchased season boxes, but inexpensive tickets made the genre available to persons of lesser means. The genre spread quickly, and various styles of opera developed. In Naples, for example, music rather than the libretto dominated opera. The genre spread to Germany and France, each developing the genre to suit the demands of its audiences. For example, ballet became an essential component of French opera. Eventually, “opera became the profligate art as large casts and lavish settings made it the most expensive public entertainment. It was the only art that without embarrassment called itself ‘grand’” (Boorstin 467). Contemporary Opera Productions Opera continues to be popular. According to a 2002 report released by the National Endowment for the Arts, 6.6 million adults attended at least one live opera performance in 2002, and 37.6 million experienced opera on television, video, radio, audio recording or via the Internet. Some think that it is a dying art form, while others think to the contrary, that it is a living art form because of its complexity and “ability to probe deeper into the human experience than any other art form” (Berger 3). Some directors change the setting of operas with perhaps the most famous contemporary proponent of this approach being Peter Sellars, who made drastic changes to three of Mozart’s most famous operas. Le Nozze di Figaro, originally set in 18th-century Seville, was set by Sellars in a luxury apartment in the Trump Tower in New York City; Sellars set Don Giovanni in contemporary Spanish Harlem rather than 17th century Seville; and for Cosi Fan Tutte, Sellars chose a diner on Cape Cod rather than 18th century Naples. As one of the more than six million Americans who attend live opera each year, I have experienced several updated productions, which made me reflect on the convergence or cross-over between high culture and popular culture. In 2000, I attended a production of Don Giovanni at the Estates Theatre in Prague, the very theatre where Mozart conducted the world premiere in 1787. In this production, Don Giovanni was a fashion designer known as “Don G” and drove a BMW. During the 1999-2000 season, Los Angeles Opera engaged film director Bruce Beresford to direct Verdi’s Rigoletto. Beresford updated the original setting of 16th century Mantua to 20th century Hollywood. The lead tenor, rather than being the Duke of Mantua, was a Hollywood agent known as “Duke Mantua.” In the first act, just before Marullo announces to the Duke’s guests that the jester Rigoletto has taken a mistress, he gets the news via his cell phone. Director Ian Judge set the 2004 production of Le Nozze di Figaro in the 1950s. In one of the opening productions of the 2006-07 LA opera season, Vincent Patterson also chose the 1950s for Massenet’s Manon rather than France in the 1720s. This allowed the title character to appear in the fourth act dressed as Marilyn Monroe. Excerpts from the dress rehearsal can be seen on YouTube. Most recently, I attended a production of Ariane et Barbe-Bleu at the Paris Opera. The original setting of the Maeterlinck play is in Duke Bluebeard’s castle, but the time period is unclear. However, it is doubtful that the 1907 opera based on an 1899 play was meant to be set in what appeared to be a mental institution equipped with surveillance cameras whose screens were visible to the audience. The critical and audience consensus seemed to be that the opera was a musical success but a failure as a production. James Shore summed up the audience reaction: “the production team was vociferously booed and jeered by much of the house, and the enthusiastic applause that had greeted the singers and conductor, immediately went nearly silent when they came on stage”. It seems to me that a new class-related taste has emerged; the opera genre has shot out a subdivision which I shall call “post-modern morphologies,” that may appeal to a larger pool of people. Hence, class, age, gender, and race are becoming more important factors in conceptualising opera productions today than in the past. I do not consider these productions as new adaptations because the libretto and the music are originals. What changes is the fact that both text and sound are taken to a higher dimension by adding iconographic images that stimulate people’s brains. When asked in an interview why he often changes the setting of an opera, Ian Judge commented, “I try to find the best world for the story and characters to operate in, and I think you have to find a balance between the period the author set it in, the period he conceived it in and the nature of theatre and audiences at that time, and the world we live in.” Hence, the world today is complex, interconnected, borderless and timeless because of advanced technologies, and updated opera productions play with symbols that offer multiple meanings that reflect the world we live in. It may be that television and film have influenced opera production. Character tenor Graham Clark recently observed in an interview, “Now the situation has changed enormously. Television and film have made a lot of things totally accessible which they were not before and in an entirely different perception.” Director Ian Judge believes that television and film have affected audience expectations in opera. “I think audiences who are brought up on television, which is bad acting, and movies, which is not that good acting, perhaps require more of opera than stand and deliver, and I have never really been happy with someone who just stands and sings.” Sociologist Wendy Griswold states that culture reflects social reality and the meaning of a particular cultural object (such as opera), originates “in the social structures and social patterns it reflects” (22). Screens of various technologies are embedded in our lives and normalised as extensions of our bodies. In those opera productions in which directors change the time and place of opera plots, use technology, and are less concerned with what the composer or librettist intended (which we can only guess), the iconographic images create multi valances, textuality similar to Mikhail Bakhtin’s notion of multiplicity of voices. Hence, a plurality of meanings. Plàcido Domingo, the Eli and Edyth Broad General Director of Los Angeles Opera, seeks to take advantage of the company’s proximity to the film industry. This is evidenced by his having engaged Bruce Beresford to direct Rigoletto and William Friedkin to direct Ariadne auf Naxos, Duke Bluebeard’s Castle and Gianni Schicchi. Perhaps the most daring example of Domingo’s approach was convincing Garry Marshall, creator of the television sitcom Happy Days and who directed the films Pretty Woman and The Princess Diaries, to direct Jacques Offenbach’s The Grand Duchess of Gerolstein to open the company’s 20th anniversary season. When asked how Domingo convinced him to direct an opera for the first time, Marshall responded, “he was insistent that one, people think that opera is pretty elitist, and he knew without insulting me that I was not one of the elitists; two, he said that you gotta make a funny opera; we need more comedy in the operetta and opera world.” Marshall rewrote most of the dialogue and performed it in English, but left the “songs” untouched and in the original French. He also developed numerous sight gags and added characters including a dog named Morrie and the composer Jacques Offenbach himself. Did it work? Christie Grimstad wrote, “if you want an evening filled with witty music, kaleidoscopic colors and hilariously good singing, seek out The Grand Duchess. You will not be disappointed.” The FanFaire Website commented on Domingo’s approach of using television and film directors to direct opera: You’ve got to hand it to Plàcido Domingo for having the vision to draw on Hollywood’s vast pool of directorial talent. Certainly something can be gained from the cross-fertilization that could ensue from this sort of interaction between opera and the movies, two forms of entertainment (elitist and perennially struggling for funds vs. popular and, it seems, eternally rich) that in Los Angeles have traditionally lived separate lives on opposite sides of the tracks. A wider audience, for example, never a problem for the movies, can only mean good news for the future of opera. So, did the Marshall Plan work? Purists of course will always want their operas and operettas ‘pure and unadulterated’. But with an audience that seemed to have as much fun as the stellar cast on stage, it sure did. Critic Alan Rich disagrees, calling Marshall “a representative from an alien industry taking on an artistic product, not to create something innovative and interesting, but merely to insult.” Nevertheless, the combination of Hollywood and opera seems to work. The Los Angeles Opera reported that the 2005-2006 season was its best ever: “ticket revenues from the season, which ended in June, exceeded projected figures by nearly US$900,000. Seasonal attendance at the Dorothy Chandler Pavilion stood at more than 86% of the house’s capacity, the largest percentage in the opera’s history.” Domingo continues with the Hollywood connection in the upcoming 2008-2009 season. He has reengaged William Friedkin to direct two of Puccini’s three operas titled collectively as Il Trittico. Friedkin will direct the two tragedies, Il Tabarro and Suor Angelica. Although Friedkin has already directed a production of the third opera in Il Trittico for Los Angeles, the comedy Gianni Schicchi, Domingo convinced Woody Allen to make his operatic directorial debut with this work. This can be viewed as another example of the desire to make opera and popular culture more equal. However, some, like Alan Rich, may see this attempt as merely insulting rather than interesting and innovative. With a top ticket price in Los Angeles of US$238 per seat, opera seems to continue to be elitist. Berger (2005) concurs with this idea and gives his rationale for elitism: there are rich people who support and attend the opera; it is an imported art from Europe that causes some marginalisation; opera is not associated with something being ‘moral,’ a concept engrained in American culture; it is expensive to produce and usually funded by kings, corporations, rich people; and the opera singers are rare –usually one in a million who will have the vocal quality to sing opera arias. Furthermore, Nicholas Kenyon commented in the early 1990s: “there is suspicion that audiences are now paying more and more money for their seats to see more and more money spent on stage” (Kenyon 3). Still, Garry Marshall commented that the budget for The Grand Duchess was US$2 million, while his budget for Runaway Bride was US$72 million. Kenyon warns, “Such popularity for opera may be illusory. The enjoyment of one striking aria does not guarantee the survival of an art form long regarded as over-elitist, over-recondite, and over-priced” (Kenyon 3). A recent development is the Metropolitan Opera’s decision to simulcast live opera performances from the Met stage to various cinemas around the world. These HD transmissions began with the 2006-2007 season when six performances were broadcast. In the 2007-2008 season, the schedule has expanded to eight live Saturday matinee broadcasts plus eight recorded encores broadcast the following day. According to The Los Angeles Times, “the Met’s experiment of merging film with live performance has created a new art form” (Aslup). Whether or not this is a “new art form,” it certainly makes world-class live opera available to countless persons who cannot travel to New York and pay the price for tickets, when they are available. In the US alone, more than 350 cinemas screen these live HD broadcasts from the Met. Top ticket price for these performances at the Met is US$375, while the lowest price is US$27 for seats with only a partial view. Top price for the HD transmissions in participating cinemas is US$22. This experiment with live simulcasts makes opera more affordable and may increase its popularity; combined with updated stagings, opera can engage a much larger audience and hope for even a mass consumption. Is opera moving closer and closer to popular culture? There still seems to be an aura of elitism and snobbery about opera. However, Plàcido Domingo’s attempt to join opera with Hollywood is meant to break the barriers between high and popular culture. The practice of updating opera settings is not confined to Los Angeles. As mentioned earlier, the idea can be traced to post World War II England, and is quite common in Europe. Examples include Erich Wonder’s approach to Wagner’s Ring, making Valhalla, the mythological home of the gods and typically a mountaintop, into the spaceship Valhalla, as well as my own experience with Don Giovanni in Prague and Ariane et Barbe-Bleu in Paris. Indeed, Sutcliffe maintains, “Great classics in all branches of the arts are repeatedly being repackaged for a consumerist world that is increasingly and neurotically self-obsessed” (61). Although new operas are being written and performed, most contemporary performances are of operas by Verdi, Mozart, and Puccini (www.operabase.com). This means that audiences see the same works repeated many times, but in different interpretations. Perhaps this is why Sutcliffe contends, “since the 1970s it is the actual productions that have had the novelty value grabbed by the headlines. Singing no longer predominates” (Sutcliffe 57). If then, as Sutcliffe argues, “operatic fashion through history may be a desire for novelty, new formulas displacing old” (Sutcliffe 65), then the contemporary practice of changing the original settings is simply the latest “new formula” that is replacing the old ones. If there are no new words or new music, then what remains are new methods of performance, hence the practice of changing time and place. Opera is a complex art form that has evolved over the past 400 years and continues to evolve, but will it survive? The underlining motives for directors changing the time and place of opera performances are at least three: for aesthetic/artistic purposes, financial purposes, and to reach an audience from many cultures, who speak different languages, and who have varied tastes. These three reasons are interrelated. In 1996, Sutcliffe wrote that there has been one constant in all the arguments about opera productions during the preceding two decades: “the producer’s wish to relate the works being staged to contemporary circumstances and passions.” Although that sounds like a purely aesthetic reason, making opera relevant to new, multicultural audiences and thereby increasing the bottom line seems very much a part of that aesthetic. It is as true today as it was when Sutcliffe made the observation twelve years ago (60-61). My own speculation is that opera needs to attract various audiences, and it can only do so by appealing to popular culture and engaging new forms of media and technology. Erickson concludes that the number of upper status people who are exclusively faithful to fine arts is declining; high status people consume a variety of culture while the lower status people are limited to what they like. Research in North America, Europe, and Australia, states Erickson, attest to these trends. My answer to the question can stage directors make opera and popular culture “equal” is yes, and they can do it successfully. Perhaps Stanley Sharpless summed it up best: After his Eden triumph, When the Devil played his ace, He wondered what he could do next To irk the human race, So he invented Opera, With many a fiendish grin, To mystify the lowbrows, And take the highbrows in. References The Grand Duchess. 2005. 3 Feb. 2008 < http://www.ffaire.com/Duchess/index.htm >.Aslup, Glenn. “Puccini’s La Boheme: A Live HD Broadcast from the Met.” Central City Blog Opera 7 Apr. 2008. 24 Apr. 2008 < http://www.centralcityopera.org/blog/2008/04/07/puccini%E2%80%99s- la-boheme-a-live-hd-broadcast-from-the-met/ >.Berger, William. Puccini without Excuses. New York: Vintage, 2005.Boorstin, Daniel. The Creators: A History of Heroes of the Imagination. New York: Random House, 1992.Bourdieu, Pierre. Distinction: A Social Critique of the Judgment of Taste. Cambridge: Harvard UP, 1984.Clark, Graham. “Interview with Graham Clark.” The KCSN Opera House, 88.5 FM. 11 Aug. 2006.DiMaggio, Paul. “Cultural Capital and School Success.” American Sociological Review 47 (1982): 189-201.DiMaggio, Paul. “Classification in Art.”_ American Sociological Review_ 52 (1987): 440-55.Elson, C. Louis. “Opera.” Elson’s Music Dictionary. Boston: Oliver Ditson, 1905.Erickson, H. Bonnie. “The Crisis in Culture and Inequality.” In W. Ivey and S. J. Tepper, eds. Engaging Art: The Next Great Transformation of America’s Cultural Life. New York: Routledge, 2007.Fanfaire.com. “At Its 20th Anniversary Celebration, the Los Angeles Opera Had a Ball with The Grand Duchess.” 24 Apr. 2008 < http://www.fanfaire.com/Duchess/index.htm >.Gans, J. Herbert. Popular Culture and High Culture: An Analysis and Evaluation of Taste. New York: Basic Books, 1977.Grimstad, Christie. Concerto Net.com. 2005. 12 Jan. 2008 < http://www.concertonet.com/scripts/review.php?ID_review=3091 >.Grisworld, Wendy. Cultures and Societies in a Changing World. Thousand Oaks, CA: Pine Forge Press, 1994.Grout, D. Jay. A History of Western Music. Shorter ed. New York: W.W. Norton & Company, Inc, 1964.Halle, David. “High and Low Culture.” The Blackwell Encyclopedia of Sociology. London: Blackwell, 2006.Judge, Ian. “Interview with Ian Judge.” The KCSN Opera House, 88.5 FM. 22 Mar. 2006.Harper, Douglas. Online Etymology Dictionary. 2001. 19 Nov. 2006 < http://www.etymonline.com/index.php?search=opera&searchmode=none >.Kenyon, Nicholas. “Introduction.” In A. Holden, N. Kenyon and S. Walsh, eds. The Viking Opera Guide. New York: Penguin, 1993.Lamont, Michele, and Marcel Fournier. Cultivating Differences: Symbolic Boundaries and the Making of Inequality. Chicago: U of Chicago P, 1992.Lord, M.G. “Shlemiel! Shlemozzle! And Cue the Soprano.” The New York Times 4 Sep. 2005.Los Angeles Opera. “LA Opera General Director Placido Domingo Announces Results of Record-Breaking 20th Anniversary Season.” News release. 2006.Marshall, Garry. “Interview with Garry Marshall.” The KCSN Opera House, 88.5 FM. 31 Aug. 2005.National Endowment for the Arts. 2002 Survey of Public Participation in the Arts. Research Division Report #45. 5 Feb. 2008 < http://www.nea.gov/pub/NEASurvey2004.pdf >.NCM Fanthom. “The Metropolitan Opera HD Live.” 2 Feb. 2008 < http://fathomevents.com/details.aspx?seriesid=622&gclid= CLa59NGuspECFQU6awodjiOafA >.Opera Today. James Sobre: Ariane et Barbe-Bleue and Capriccio in Paris – Name This Stage Piece If You Can. 5 Feb. 2008 < http://www.operatoday.com/content/2007/09/ariane_et_barbe_1.php >.Rich, Alan. “High Notes, and Low.” LA Weekly 15 Sep. 2005. 6 May 2008 < http://www.laweekly.com/stage/a-lot-of-night-music/high-notes-and-low/8160/ >.Sharpless, Stanley. “A Song against Opera.” In E. O. Parrott, ed. How to Be Tremendously Tuned in to Opera. New York: Penguin, 1990.Shore, James. Opera Today. 2007. 4 Feb. 2008 < http://www.operatoday.com/content/2007/09/ariane_et_barbe_1.php >.Sutcliffe, Tom. Believing in Opera. Princeton, New Jersey: Princeton UP, 1996.YouTube. “Manon Sex and the Opera.” 24 Apr. 2008 < http://www.youtube.com/watch?v=YiBQhr2Sy0k >.

Are male porn stars full-fledged citizens? Recent political developments make this question more than rhetorical. The Bush Justice Department, led by Attorney General John Ashcroft, has targeted the porn industry, beginning with its prosecution of Extreme Associates. More recently, the President requested an increase in the FBI’s 2005 budget for prosecuting obscenity, one of the few budget increases for the Bureau outside of its anti-terrorism program (Schmitt A1). To be sure, the concept of “citizen” is itself vexed. Citizenship, when obtained or granted, ostensibly legitimates a subject and opens up pathways to privilege: social, political, economic, etc. Yet all citizens do not seem to be created equal. “There is, in the operation of state-defined rules and in common practices an assumption of moral worth in which de facto as opposed to de jure rights of citizenship are defined as open to those who are deserving or who are capable of acting responsibly,” asserts feminist critic Linda McDowell. “The less deserving and the less responsible are defined as unworthy of or unfitted for the privileges of full citizenship” (150). Under this rubric, a citizen must measure up to a standard of “moral worth”—an individual is not a full-fledged citizen merely on the basis of birth or geographical placement. As McDowell concludes, “citizenship is not an inclusive but an exclusive concept” (150). Thus, in figuring out how male porn stars stand in regard to the question of citizenship, we must ask who determines “moral worth,” who distinguishes the less from the more deserving, and how people have come to agree on the “common practices” of citizenship. Many critics writing about citizenship, including McDowell, Michael Warner, Lauren Berlant, Russ Castronovo, Robyn Wiegman, Michael Moon, and Cathy Davidson (to name only a few) have located the nexus of “moral worth” in the body. In particular, the ability to make the body abstract, invisible, and non-identifiable has been the most desirable quality for a citizen to possess. White men seem ideally situated for such acts of “decorporealization,” and the white male body has been installed as the norm for citizenship. Conversely, women, people of color, and the ill and disabled, groups that are frequently defined by their very embodiment, find themselves more often subject to regulation. If the white male body is the standard, however, for “moral worth,” the white male porn star would seem to disrupt such calculations. Clearly, the profession demands that these men put their bodies very much in evidence, and the most famous porn stars, like John C. Holmes and Ron Jeremy, derive much of their popularity from their bodily excess. Jeremy’s struggle for “legitimacy,” and the tenuous position of men in the porn industry in general, demonstrate that even white males, when they cannot or will not aspire to abstraction and invisibility, will lose the privileges of citizenship. The right’s attack on pornography can thus be seen as yet another attempt to regulate and restrict citizenship, an effort that forces Jeremy and the industry that made him famous struggle for strategies of invisibility that will permit some mainstream acceptance. In American Anatomies, Robyn Wiegman points out that the idea of democratic citizenship rested on a distinct sense of the abstract and non-particular. The more “particular” an individual was, however, the less likely s/he could pass into the realm of citizen. “For those trapped by the discipline of the particular (women, slaves, the poor),” Wiegman writes, “the unmarked and universalized particularity of the white masculine prohibited their entrance into the abstraction of personhood that democratic equality supposedly entailed” (49). The norm of the “white masculine” caused others to signify “an incontrovertible difference” (49), so people who were visibly different (or perceived as visibly different) could be tyrannized over and regulated to ensure the purity of the norm. Like Wiegman, Lauren Berlant has written extensively about the ways in which the nation recognizes only one “official” body: “The white, male body is the relay to legitimation, but even more than that, the power to suppress that body, to cover its tracks and its traces, is the sign of real authority, according to constitutional fashion” (113). Berlant notes that “problem citizens”—most notably women of color—struggle with the problem of “surplus embodiment.” They cannot easily suppress their bodies, so they are subjected to the regulatory power of a law that defines them and consequently opens their bodies up to violation. To escape their “surplus embodiment,” those who can seek abstraction and invisibility because “sometimes a person doesn’t want to seek the dignity of an always-already-violated body, and wants to cast hers off, either for nothingness, or in a trade for some other, better model” (114). The question of “surplus embodiment” certainly has resonance for male porn stars. Peter Lehman has argued that hardcore pornography relies on images of large penises as signifiers of strength and virility. “The genre cannot tolerate a small, unerect penis,” Lehman asserts, “because the sight of the organ must convey the symbolic weight of the phallus” (175). The “power” of male porn stars derives from their visibility, from “meat shots” and “money shots.” Far from being abstract, decorporealized “persons,” male porn stars are fully embodied. In fact, the more “surplus embodiment” they possess, the more famous they become. Yet the very display that makes white male porn stars famous also seemingly disqualifies them from the “legitimacy” afforded the white male body. In the industry itself, male stars are losing authority to the “box-cover girls” who sell the product. One’s “surplus embodiment” might be a necessity for working in the industry, but, as Susan Faludi notes, “by choosing an erection as the proof of male utility, the male performer has hung his usefulness, as porn actor Jonathan Morgan observed, on ‘the one muscle on our body we can’t flex’” (547). When that muscle doesn’t work, a male porn star doesn’t become an abstraction—he becomes “other,” a joke, swept aside and deemed useless. Documentary filmmaker Scott J. Gill recognizes the tenuousness of the “citizenship” of male porn stars in his treatment of Ron Jeremy, “America’s most famous porn star.” The film, Porn Star: The Legend of Ron Jeremy (2001), opens with a clear acknowledgment of Jeremy’s body, as one voiceover explains how his nickname, “the Hedgehog,” derives from the fact that Jeremy is “small, fat, and very hairy.” Then, Gill intercuts the comments of various Jeremy fans: “An idol to an entire generation,” one young man opines; “One of the greatest men this country has ever seen,” suggests another. This opening scene concludes with an image of Jeremy, smirking and dressed in a warm-up suit with a large dollar sign necklace, standing in front of an American flag (an image repeated at the end of the film). This opening few minutes posit the Hedgehog as super-citizen, embraced as few Americans are. “Everyone wants to be Ron Jeremy,” another young fan proclaims. “They want his life.” Gill also juxtaposes “constitutional” forms of legitimacy that seemingly celebrate Jeremy’s bodily excess with the resultant discrimination that body actually engenders. In one clip, Jeremy exposes himself to comedian Rodney Dangerfield, who then sardonically comments, “All men are created equal—what bullshit!” Later, Gill employs a clip of a film in which Jeremy is dressed like Ben Franklin while in a voiceover porn director/historian Bill Margold notes that the Freeman decision “gave a birth certificate to a bastard industry—it legitimized us.” The juxtaposition thus posits Jeremy as a “founding father” of sorts, the most recognizable participant in an industry now going mainstream. Gill, however, emphasizes the double-edged nature of Jeremy’s fame and the price of his display. Immediately after the plaudits of the opening sequence, Gill includes clips from various Jeremy talk show appearances in which he is denounced as “scum” and told “You should go to jail just for all the things that you’ve helped make worse in this country” and “You should be shot.” Gill also shows a clearly dazed Jeremy in close-up confessing, “I hate myself. I want to find a knife and slit my wrists.” Though Jeremy does not seem serious, this comment comes into better focus as the film unfolds. Jeremy’s efforts to go “legit,” to break into mainstream film and leave his porn life behind, keep going off the tracks. In the meantime, Jeremy must fulfill his obligations to his current profession, including getting a monthly HIV test. “There’ll be one good thing about eventually getting out of the porn business,” he confesses as Gill shows scenes of a clearly nervous Jeremy awaiting results in a clinic waiting room, “to be able to stop taking these things every fucking month.” Gill shows that the life so many others would love to have requires an abuse of the body that fans never see. Jeremy is seeking to cast off that life, “either for nothingness, or in a trade for some other, better model.” Behind this “legend” is unseen pain and longing. Gill emphasizes the dichotomy between Jeremy (illegitimate) and “citizens” in his own designations. Adam Rifkin, director of Detroit Rock City, in which Jeremy has a small part, and Troy Duffy, another Jeremy pal, are referred to as “mainstream film directors.” When Jeremy returns to his home in Queens to visit his father, Arnold Hyatt is designated “physicist.” In fact, Jeremy’s father forbids his son from using the family name in his porn career. “I don’t want any confusion between myself and his line of work,” Hyatt confesses, “because I’m retired.” Denied his patronym, Jeremy is truly “illegitimate.” Despite his father’s understanding and support, Jeremy is on his own in the business he has chosen. Jeremy’s reputation also gets in the way of his mainstream dreams. “Sometimes all this fame can hurt you,” Jeremy himself notes. Rifkin admits that “People recognize Ron as a porn actor and immediately will ask me to remove him from the final cut.” Duffy concurs that Jeremy’s porn career has made him a pariah for some mainstream producers: “Stigma attached to him, and that’s all anybody’s ever gonna see.” Jeremy’s visibility, the “stigma” that people have “seen,” namely, his large penis and fat, hairy body, denies him the abstract personhood he needs to go “legitimate.” Thus, whether through the concerted efforts of the Justice Department or the informal, personal angst of a producer fearing a backlash against a film, Jeremy, as a representative of an immoral industry, finds himself subject to regulation. Indeed, as his “legitimate” filmography indicates, Jeremy has been cut out of more than half the films he has appeared in. The issue of “visibility” as the basis for regulation of hardcore pornography has its clearest articulation in Potter Stewart’s famous proclamation “I know it when I see it.” But as Bob Woodward and Scott Armstrong report in The Brethren, Stewart was not the only Justice who used visibility as a standard. Byron White’s personal definition was “no erect penises, no intercourse, no oral or anal sodomy” (193). William Brennan, too, had what his clerks called “the limp dick standard” (194). Erection, what Lehman has identified as the conveyance of the phallus, now became the point of departure for regulation, transferring, once again, the phallus to the “law.” When such governmental regulation failed First Amendment ratification, other forms of societal regulation kicked in. The porn industry has accommodated itself to this regulation, as Faludi observes, in its emphasis on “soft” versions of product for distribution to “legitimate” outlets like cable and hotels. “The version recut for TV would have to be entirely ‘soft,’” Faludi notes, “which meant, among other things, no erect penises and no semen” (547). The work of competent “woodsmen” like Jeremy now had to be made invisible to pass muster. Thus, even the penis could be conveyed to the viewer, a “fantasy penis,” as Katherine Frank has called it, that can be made to correlate to that viewer’s “fantasized identity” of himself (133-4). At the beginning of Porn Star, during the various homages paid to Jeremy, one fan draws a curious comparison: “There’s Elvis, and then there’s Ron.” Elvis’s early career had certainly been plagued by criticism related to his bodily excess. Musicologist Robert Fink has recently compared Presley’s July 2, 1956, recording of “Hound Dog” to music for strip tease, suggesting that Elvis used such subtle variations to challenge the law that was constantly impinging on his performances: “The Gray Lady was sensitive to the presence of quite traditional musical erotics—formal devices that cued the performer and audience to experience their bodies sexually—but not quite hep enough to accept a male performer recycling these musical signifiers of sex back to a female audience” (99). Eventually, though, Elvis stopped rebelling and sought respectability. Writing to President Nixon on December 21, 1970, Presley offered his services to help combat what he perceived to be a growing cultural insurgency. “The drug culture, the hippie elements, the SDS, Black Panthers, etc., do not consider me as their enemy or as they call it, The Establishment,” Presley confided. “I call it America and I love it” (Carroll 266). In short, Elvis wanted to use his icon status to help reinstate law and order, in the process demonstrating his own patriotism, his value and worth as a citizen. At the end of Porn Star, Jeremy, too, craves legitimacy. Whereas Elvis appealed to Nixon, Jeremy concludes by appealing to Steven Spielberg. Elvis received a badge from Nixon designating him as “special assistant” for the Bureau of Narcotics and Dangerous Drugs. Presumably Jeremy invests his legitimacy in a SAG card. Kenny Dollar, a Jeremy friend, unironically summarizes the final step the Hedgehog must take: “It’s time for Ron to go on and reach his full potential. Let him retire his dick.” That Jeremy must do the latter before having a chance for the former illustrates how “surplus embodiment” and “citizenship” remain inextricably entangled and mutually exclusive. References Berlant, Lauren. “National Brands/National Body: Imitation of Life.” Comparative American Identities: Race, Sex and Nationality in the Modern Text. Ed. Hortense Spillers. New York: Routledge, 1991: 110-140. Carroll, Andrew, ed. Letters of a Nation: A Collection of Extraordinary American Letters. New York: Broadway Books, 1999. Castronovo, Russ and Nelson, Dana D., eds. Materializing Democracy: Toward a Revitalized Cultural Politics. Durham: Duke University Press, 2002. Faludi, Susan. Stiffed: The Betrayal of the American Man. New York: William Morrow and Company, Inc., 1999. Fink, Robert. “Elvis Everywhere: Musicology and Popular Music Studies at the Twilight of the Canon.” Rock Over the Edge: Transformations in Popular Music Culture. Eds. Roger Beebe, Denise Fulbrook, and Ben Saunders. Durham: Duke University Press, 2002: 60-109. Frank, Katherine. G-Strings and Sympathy: Strip Club Regulars and Male Desire. Durham: Duke University Press, 2002. Gill, Scott J., dir. Porn Star: The Legend of Ron Jeremy. New Video Group, 2001. Lehman, Peter. Running Scared: Masculinity and the Representation of the Male Body. Philadelphia: Temple University Press, 1993. McDowell, Linda. Gender, Identity and Place: Understanding Feminist Geographies. Minneapolis: University of Minnesota Press, 1999. Moon, Michael and Davidson, Cathy N., eds. Subjects and Citizens: From Oroonoko to Anita Hill. Durham: Duke University Press, 1995. Schmitt, Richard B. “U. S. Plans to Escalate Porn Fight.” The Los Angeles Times 14 February 2004. A1. Wiegman, Robyn. American Anatomies: Theorizing Race and Gender. Durham: Duke University Press, 1995. Woodward, Bob and Armstrong, Scott. The Brethren: Inside the Supreme Court. New York: Simon and Schuster, 1979. MLA Style Russell, David. "The Tumescent Citizen: The Legend of Ron Jeremy." M/C Journal 7.4 (2004). 10 October 2004 <http://www.media-culture.org.au/0410/01_citizen.php>. APA Style Russell, D. (2004 Oct 11). The Tumescent Citizen: The Legend of Ron Jeremy, M/C Journal, 7(4). Retrieved Oct 10 2004 from <http://www.media-culture.org.au/0410/01_citizen.php>

Despite an increasing number of studies focusing on leadership at Vietnamese small and medium sized enteprises (SMEs), there is a lack of empirical research on collective leadership and development of effective top management team (TMT). The purpose of this paper is to review the literature with a view of characteristics forming an effective TMT. Taking the team effectiveness theory, upper echelons theory and behavioral theory of the firm, theoretical characteristics of effective TMT was created, and then an empirical research was conducted on a sample of 141 SMEs. The common characteristics of an effective TMT are identified, including shared vision, optimal team size, role clarity, age diversity, functional background diversity, regular communication, solidarity and collective decision making. The study makes several contributions to the existing literature on effective TMT development at SMEs. 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The Garden of Eden is the original surveillance state. God creates the heavens and the earth, turns on the lights, inspects everything that he has made and, behold, finds it very good. But then the creation attempts to acquire the surveillant properties of the creator. In Genesis 3, a serpent explains to Eve the virtues of forbidden fruit: “Ye shall not die: For God doth know that in the day ye eat thereof, then your eyes shall be opened, and ye shall be as gods, knowing good and evil” (Genesis 3: 4–5). Adam’s and Eve’s eyes are certainly opened (sufficiently so to necessitate figleaves), but in the next verse, God’s superior surveillance system has found them out. The power relationship Genesis illustrates has prompted many – the Romantics in their seditious appropriations of Paradise Lost, for instance – to question whether Eden is all that “good” after all. Why was God so concerned for Eve and Adam not to see? For that matter, why was he not there to intercept the serpent, but so promptly on the scene of humanity’s crime? Various answers (that God planned the Fall because it would enable him to demonstrate supreme love through Jesus, that Eve and Adam were wilfully wrong to grasp for equality with the Creator of the Universe, that God could not intervene in the temptation because it would compromise humanity’s free will) do not alter the flaw in God’s perfect garden state. Consciousness of this imperfection surfaces repeatedly in Western utopian narratives. The very existence of such narratives points to a humanist distrust in God as social engineer; the fact that these secular Edens are themselves often flawed suggests both a parody of the original Eden and an admission that humans are not up to the task of social engineering either. Thomas More’s Utopia and Ridley Scott’s Blade Runner – one the ostensible depiction of a new Eden, the other an outright dystopic inferno – address the association of Eden (or the Creator) with surveillance, and so undermine the ideality of the prelapsarian Garden. The archetypal power relationship, that of All-Seeing Creator with always-seen creation, is reconfigured sans God: in Utopia, with society itself performing the work of a transcendent surveillance system; in Blade Runner, with the multi-planetary Tyrell corporation doing so. In both cases, the Omnisurveillant is stripped of the mitigating quality of being God, and so exposed as oppressive, unjust, an affront to the idea of perfection. Like Eden, the eponymous island of Thomas More’s Utopia is a surveillance state. Glass, we read, “is there much used” (More 55). Surveillance is decentralised and patriarchal: wives are expected to confess to their husbands, children to their mothers (More 65). Each year, every thirty families select a “syphogrant”, whose “chief and almost … only office … is to see and take heed that no man sit idle, but that every one apply his own craft with earnest diligence” (More 57). In the mess halls, “The Syphogrant and his wife sit in the midst of the high table … because from thence all the whole company is in their sight” (More 66). Elders are ranged amongst the young men so that “the sage gravity and reverence of the elders should keep the youngsters from wanton licence of words and behaviour. Forasmuch as nothing can be so secretly spoken or done at the table, but either they that sit on the one side or on the other must needs perceive it” (More 66). Not only are the Utopians subject to social surveillance, but also to a conviction of its inescapability. Believing that the dead move among them, the Utopians feel that they are being watched (even when they are not) and thus regulate their own behaviour. In his preface to The Panopticon, Jeremy Bentham extols the virtues of his surveillance machine: “Morals reformed – health preserved – industry invigorated instruction diffused – public burthens lightened – Economy seated, as it were, upon a rock – the gordian knot of the Poor-Laws are not cut, but untied – all by a simple idea in Architecture!” (Bentham 29). As Foucault points out in “Panopticism”, the Panopticon works so well because the prisoner can never know when she or he is being watched, and this uncertainty compels the prisoner into constant discipline. Atheist Bentham had created a transcendent surveillance system that would replace God in (he trusted) an increasingly secular society. Bentham’s catalogue of the Panopticon’s benefits is something of a Utopian manifesto in its own right, and his utilitarianism, based on the “greatest-happiness principle”, was prepared to embrace the surveillance system so long as that system maximised overall happiness. Perhaps Thomas More was a proto-utilitarian, prepared to take up the repressive aspects of panopticism in exchange for moral reform, health preservation, the invigoration of industry and the lightening of public burdens. On the other hand, Utopia is widely read as a deliberately ironic representation of the ideal state. Stephen Greenblatt has pointed out that More “remained ambivalent about many of his most intensely felt perceptions” in Utopia, and he offers the text’s various ironising elements (such as the name of More’s fictitious interlocutor, Hythlodaeus, “well learned in nonsense”) as evidence (Greenblatt 54). Even the text’s title undermines its Edenic vision: as Louis Marin argues, “Utopia” could derive equally from Greek ou-topos, no-place, or eu-topos, good-place (Marin 85). More’s ambivalence about Utopia – to the extent of attributing his account of No-place to a character called Nonsense – suggests his impatience with his own flawed social vision. While Utopia is ambivalent in its depiction of the perfect state, more recent utopian narratives – Aldous Huxley’s Brave New World (1931), for instance, or George Orwell’s Nineteen Eighty-Four (1949) – are unequivocally ironic about the subordination of the individual to the perfect state. The Bible’s account of human society begins with Eden and ends with Apocalypse, in which divine surveillance reaches its inevitable conclusion in divine judgement. The utopian genre has undergone a very similar trajectory, beginning with what seem to be sincere attempts to sketch the perfect state, briefly flourishing as Europeans became first aware of Cytherean islands in the South Pacific, and, more recently, representing outright apocalypse (as in Margaret Atwood’s The Handmaid’s Tale [1986] and Ridley Scott’s Blade Runner [1992]), or at least responding pessimistically to human attempts at social engineering. Blade Runner’s dystopic inversion of biblical creation illustrates an enduring distrust in both human and divine attempts to establish Eden. The year is 2019 (only one year off 2020, perfect vision); the place is Los Angeles, the City of Angels. Corporate biomechanic Eldon Tyrell manufactures a race of robots, “replicants”, who are physically indistinguishable from humans, capable of developing emotional responses, but burdened with a four-year self-destruct mechanism. When the replicants rebel, their leader, Roy Batty, demands of Tyrell, “I want more life, Father”. Tyrell is not only “Father”, but “the god of biomechanics”; and Batty is simultaneously a reworking of Adam (the disaffected creation), Lucifer (the rebel angel) and Christ (as shown in the accompanying iconography of crucifixion and doves). The Bible’s leading actors are all present, but the City of Angels, 2019, is unmistakeably not Eden. It is a polluted, dank, flame-spewing dragon of a city, more Inferno than human habitation. The film’s oppressive film noir atmosphere relays the nausea induced by the Tyrell Corporation’s surveillance system. The Voight-Kamff test – a means of assessing emotional response (and thus determining whether an individual is human or replicant) by scanning the pupils – is a surveillance mechanism so intrusive it measures not only behaviour, but feelings. The optical imagery throughout the film reinforces the idea of permanent visibility. The result is a claustrophobic paranoia. Blade Runner is unambiguous in its pessimism about human attempts to regulate society (attempts which it shows to be reliant on surveillance, slavery and swift punishment). It seems unlikely that the God of Genesis is specifically targeted by this film’s parody of the Creator-creation power relationship – its critiques of capitalism and environmental mismanagement are much more overt – but by configuring its dramatis personae in biblical roles, Blade Runner demonstrates that the paradigm for omnisurveillant creators comes from the Bible. In turn, by placing Los Angeles, 2019, at such a distant aesthetic remove from Eden, the film portrays the omnisurveillant creator unrelieved by natural beauty. Foucault’s formulation of panopticism, that power is seeing without being seen, that being seen without seeing is disempowerment, informs all three texts – Genesis, Utopia and Blade Runner. What differentiates them, determines how perfect each text would have its world believed to be, is the extent to which its authors approve this power relationship. References Bentham, Jeremy. The Panopticon; or, The Inspection House (1787). In The Panopticon Writings. Ed. Miran Bozovic. London: Verso, 1995. 29-95. Foucault, Michel. “Panopticism”. In Discipline and Punish: the Birth of the Prison. Trans. Alan Sheridan (1977). New York: Vintage Books, 1995. 195–228. Greenblatt, Stephen. Renaissance Self-Fashioning: From More to Shakespeare. Chicago and London: U of Chicago P, 1980. Marin, Louis. Utopics: The Semiological Play of Textual Spaces. Trans. Robert A. Vollrath. Atlantic Highlands, NJ: Humanities Press International, 1990. More, Thomas. Utopia (1516). In Susan Brice, ed. Three Early Modern Utopias: Utopia, New Atlantis, The Isle of Pines. Oxford: Oxford UP, 1996. Scott, Ridley. Blade Runner: The Director’s Cut. United States, 1992. Citation reference for this article MLA Style Harley, Alexis. "Resurveying Eden: Panoptica in Imperfect Worlds." M/C Journal 8.4 (2005). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0508/02-harley.php>. APA Style Harley, A. (Aug. 2005) "Resurveying Eden: Panoptica in Imperfect Worlds," M/C Journal, 8(4). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0508/02-harley.php>.

IntroductionCirque du Soleil, the largest live entertainment company in the world, has eight standing shows in Las Vegas alone, KÀ, Love, Mystère, Zumanity, Believe, Michael Jackson ONE, Zarkana and O. Close to 150 million spectators have seen Cirque du Soleil shows since the company’s beginnings in 1984 and it is estimated that over 15 million spectators will see a Cirque du Soleil show in 2014 (Cirque du Soleil). The Cirque du Soleil concept of circus as a form of theatre, with simple, often archetypal, narrative arcs conveyed without words, virtuoso physicality with the circus artists presented as characters in a fictional world, cutting-edge lighting and visuals, extraordinary innovative staging, and the uptake of new technology for special effects can all be linked back to an early form of circus which is sometimes termed illegitimate circus. In the late 18th century and early 19th century, in the age of Romanticism, only two theatres in London, Covent Garden and Drury Lane, plus the summer theatre in the Haymarket, had royal patents allowing them to produce plays or text-based productions, and these were considered legitimate theatres. (These theatres retained this monopoly until the Theatre Regulation Act of 1843; Saxon 301.) Other circuses and theatres such as Astley’s Amphitheatre, which were precluded from performing text-based works by the terms of their licenses, have been termed illegitimate (Moody 1). Perversely, the effect of licensing venues in this way, instead of having the desired effect of enshrining some particular forms of expression and “casting all others beyond the cultural pale,” served instead to help to cultivate a different kind of theatrical landscape, “a theatrical terrain with a new, rich and varied dramatic ecology” (Reed 255). A fundamental change to the theatrical culture of London took place, and pivotal to “that transformation was the emergence of an illegitimate theatrical culture” (Moody 1) with circus at its heart. An innovative and different form of performance, a theatre of the body, featuring spectacle and athleticism emerged, with “a sensuous, spectacular aesthetic largely wordless except for the lyrics of songs” (Bratton 117).This writing sets out to explore some of the strong parallels between the aesthetic that emerged in this early illegitimate circus and the aesthetic of the Montreal-based, multi-billion dollar entertainment empire of Cirque du Soleil. Although it is not fighting against legal restrictions and can in no way be considered illegitimate, the circus of Cirque du Soleil can be seen to be the descendant of the early circus entrepreneurs and their illegitimate aesthetic which arose out of the desire to find ways to continue to attract audiences to their shows in spite of the restrictions of the licenses granted to them. BackgroundCircus has served as an inspiration for many innovatory theatre productions including Peter Brook’s Midsummer Night’s Dream (1970) and Tom Stoppard’s Jumpers (1972) as well as the earlier experiments of Meyerhold, Eisenstein, Mayakovsky and other Soviet directors of the 1920’s (Saxon 299). A. H. Saxon points out, however, that the relationship between circus and theatre is a long-standing one that begins in the late 18th century and the early 19th century, when circus itself was theatre (Saxon 299).Modern circus was founded in London in 1768 by an ex-cavalryman and his wife, Philip and Patty Astley, and consisted of spectacular stunt horse riding taking place in a ring, with acts from traditional fairs such as juggling, acrobatics, clowning and wire-walking inserted to cover the changeovers between riding acts. From the very first shows entry was by paid ticket only and the early history of circus was driven by innovative, risk-taking entrepreneurs such as Philip Astley, who indeed built so many new amphitheatres for his productions that he became known as Amphi-Philip (Jando). After years of legal tussles with the authorities concerning the legal status of this new entertainment, a limited license was finally granted in 1783 for Astley’s Amphitheatre. This license precluded the performing of plays, anything text-based, or anything which had a script that resembled a play. Instead the annual license granted allowed only for “public dancing and music” and “other public entertainments of like kind” (St. Leon 9).Corporeal Dramaturgy and TextIn the face of the ban on scripted text, illegitimate circus turned to the human body and privileged it as a means of dramatic expression. A resultant dramaturgy focusing on the expressive capabilities of the performers’ bodies emerged. “The primacy of rhetoric and the spoken word in legitimate drama gave way […] to a corporeal dramaturgy which privileged the galvanic, affective capacity of the human body as a vehicle of dramatic expression” (Moody 83). Moody proposes that the “iconography of illegitimacy participated in a broader cultural and scientific transformation in which the human body began to be understood as an eloquent compendium of visible signs” (83). Even though the company has the use of text and dramatic dialogue freely available to it, Cirque du Soleil, shares this investment in the bodies of the performers and their “galvanic, affective capacity” (83) to communicate with the audience directly without the use of a scripted text, and this remains a constant between the two forms of circus. Robert Lepage, the director of two Cirque du Soleil shows, KÀ (2004) and more recently Totem (2010), speaking about KÀ in 2004, said, “We wanted it to be an epic story told not with the use of words, but with the universal language of body movement” (Lepage cited in Fink).In accordance with David Graver’s system of classifying performers’ bodies, Cirque du Soleil’s productions most usually present performers’ ‘character bodies’ in which the performers are understood by spectators to be playing fictional roles or characters (Hurley n/p) and this was also the case with illegitimate circus which right from its very beginnings presented its performers within narratives in which the performers are understood to be playing characters. In Cirque du Soleil’s shows, as with illegitimate circus, this presentation of the performers’ character bodies is interspersed with acts “that emphasize the extraordinary training and physical skill of the performers, that is which draw attention to the ‘performer body’ but always within the context of an overall narrative” (Fricker n.p.).Insertion of Vital TextAfter audience feedback, text was eventually added into KÀ (2004) in the form of a pre-recorded prologue inserted to enable people to follow the narrative arc, and in the show Wintuk (2007) there are tales that are sung by Jim Comcoran (Leroux 126). Interestingly early illegitimate circus creators, in their efforts to circumvent the ban on using dramatic dialogue, often inserted text into their performances in similar ways to the methods Cirque du Soleil chose for KÀ and Wintuk. Illegitimate circus included dramatic recitatives accompanied by music to facilitate the following of the storyline (Moody 28) in the same way that Cirque du Soleil inserted a pre-recorded prologue to KÀ to enable audience members to understand the narrative. Performers in illegitimate circus often conveyed essential information to the audience as lyrics of songs (Bratton 117) in the same way that Jim Comcoran does in Wintuk. Dramaturgical StructuresAstley from his very first circus show in 1768 began to set his equestrian stunts within a narrative. Billy Button’s Ride to Brentford (1768), showed a tailor, a novice rider, mounting backwards, losing his belongings and being thrown off the horse when it bucks. The act ends with the tailor being chased around the ring by his horse (Schlicke 161). Early circus innovators, searching for dramaturgy for their shows drew on contemporary warfare, creating vivid physical enactments of contemporary battles. They also created a new dramatic form known as Hippodramas (literally ‘horse dramas’ from hippos the Attic Greek for Horse), a hybridization of melodrama and circus featuring the trick riding skills of the early circus pioneers. The narrative arcs chosen were often archetypal or sourced from well-known contemporary books or poems. As Moody writes, at the heart of many of these shows “lay an archetypal narrative of the villainous usurper finally defeated” (Moody 30).One of the first hippodramas, The Blood Red Knight, opened at Astley’s Amphitheatre in 1810.Presented in dumbshow, and interspersed with grand chivalric processions, the show featured Alphonso’s rescue of his wife Isabella from her imprisonment and forced marriage to the evil knight Sir Rowland and concluded with the spectacular, fiery destruction of the castle and Sir Rowland’s death. (Moody 69)Another later hippodrama, The Spectre Monarch and his Phantom Steed, or the Genii Horseman of the Air (1830) was set in China where the rightful prince was ousted by a Tartar usurper who entered into a pact with the Spectre Monarch and received,a magic ring, by aid of which his unlawful desires were instantly gratified. Virtue, predictably won out in the end, and the discomforted villain, in a final settling of accounts with his dread master was borne off through the air in a car of fire pursued by Daemon Horsemen above THE GREAT WALL OF CHINA. (Saxon 303)Karen Fricker writes of early Cirque du Soleil shows that “while plot is doubtless too strong a word, each of Cirque’s recent shows has a distinct concept or theme, that is urbanity for Saltimbanco; nomadism in Varekai (2002) and humanity’s clownish spirit for Corteo (2005), and tend to follow the same very basic storyline, which is not narrated in words but suggested by the staging that connects the individual acts” (Fricker n/p). Leroux describes the early Cirque du Soleil shows as following a “proverbial and well-worn ‘collective transformation trope’” (Leroux 122) whilst Peta Tait points out that the narrative arc of Cirque du Soleil “ might be summarized as an innocent protagonist, often female, helped by an older identity, seemingly male, to face a challenging journey or search for identity; more generally, old versus young” (Tait 128). However Leroux discerns an increasing interest in narrative devices such as action and plot in Cirque du Soleil’s Las Vegas productions (Leroux 122). Fricker points out that “with KÀ, what Cirque sought – and indeed found in Lepage’s staging – was to push this storytelling tendency further into full-fledged plot and character” (Fricker n/p). Telling a story without words, apart from the inserted prologue, means that the narrative arc of Kà is, however, very simple. A young prince and princess, twins in a mythical Far Eastern kingdom, are separated when a ceremonial occasion is interrupted by an attack by a tribe of enemy warriors. A variety of adventures follow, most involving perilous escapes from bad guys with flaming arrows and fierce-looking body tattoos. After many trials, a happy reunion arrives. (Isherwood)This increasing emphasis on developing a plot and a narrative arc positions Cirque as moving closer in dramaturgical aesthetic to illegitimate circus.Visual TechnologiesTo increase the visual excitement of its shows and compensate for the absence of spoken dialogue, illegitimate circus in the late 18th and early 19th century drew on contemporaneous and emerging visual technologies. Some of the new visual technologies that Astley’s used have been termed pre-cinematic, including the panorama (or diorama as it is sometimes called) and “the phantasmagoria and other visual machines… [which] expanded the means through which an audience could be addressed” (O’Quinn, Governance 312). The panorama or diorama ran in the same way that a film runs in an analogue camera, rolling between vertical rollers on either side of the stage. In Astley’s production The Siege and Storming of Seringapatam (1800) he used another effect almost equivalent to a modern day camera zoom-in by showing scenic back drops which, as they moved through time, progressively moved geographically closer to the battle. This meant that “the increasing enlargement of scale-each successive scene has a smaller geographic space-has a telescopic event. Although the size of the performance space remains constant, the spatial parameters of the spectacle become increasingly magnified” (O’Quinn, Governance 345). In KÀ, Robert Lepage experiments with “cinematographic stage storytelling on a very grand scale” (Fricker n.p.). A KÀ press release (2005) from Cirque du Soleil describes the show “as a cinematic journey of aerial adventure” (Cirque du Soleil). Cirque du Soleil worked with ground-breaking visual technologies in KÀ, developing an interactive projected set. This involves the performers controlling what happens to the projected environment in real time, with the projected scenery responding to their movements. The performers’ movements are tracked by an infra-red sensitive camera above the stage, and by computer software written by Interactive Production Designer Olger Förterer. “In essence, what we have is an intelligent set,” says Förterer. “And everything the audience sees is created by the computer” (Cirque du Soleil).Contemporary Technology Cutting edge technologies, many of which came directly from contemporaneous warfare, were introduced into the illegitimate circus performance space by Astley and his competitors. These included explosions using redfire, a new military explosive that combined “strontia, shellac and chlorate of potash, [which] produced […] spectacular flame effects” (Moody 28). Redfire was used for ‘blow-ups,’ the spectacular explosions often occurring at the end of the performance when the villain’s castle or hideout was destroyed. Cirque du Soleil is also drawing on contemporary military technology for performance projects. Sparked: A Live interaction between Humans and Quadcopters (2014) is a recent short film released by Cirque du Soleil, which features the theatrical use of drones. The new collaboration between Cirque du Soleil, ETH Zurich and Verity Studios uses 10 quadcopters disguised as animated lampshades which take to the air, “carrying out the kinds of complex synchronized dance manoeuvres we usually see from the circus' famed acrobats” (Huffington Post). This shows, as with early illegitimate circus, the quick theatrical uptake of contemporary technology originally developed for use in warfare.Innovative StagingArrighi writes that the performance space that Astley developed was a “completely new theatrical configuration that had not been seen in Western culture before… [and] included a circular ring (primarily for equestrian performance) and a raised theatre stage (for pantomime and burletta)” (177) joined together by ramps that were large enough and strong enough to allow horses to be ridden over them during performances. The stage at Astley’s Amphitheatre was said to be the largest in Europe measuring over 130 feet across. A proscenium arch was installed in 1818 which could be adjusted in full view of the audience with the stage opening changing anywhere in size from forty to sixty feet (Saxon 300). The staging evolved so that it had the capacity to be multi-level, involving “immense [moveable] platforms or floors, rising above each other, and extending the whole width of the stage” (Meisel 214). The ability to transform the stage by the use of draped and masked platforms which could be moved mechanically, proved central to the creation of the “new hybrid genre of swashbuckling melodramas on horseback, or ‘hippodramas’” (Kwint, Leisure 46). Foot soldiers and mounted cavalry would fight their way across the elaborate sets and the production would culminate with a big finale that usually featured a burning castle (Kwint, Legitimization 95). Cirque du Soleil’s investment in high-tech staging can be clearly seen in KÀ. Mark Swed writes that KÀ is, “the most lavish production in the history of Western theatre. It is surely the most technologically advanced” (Swed). With a production budget of $165 million (Swed), theatre designer Michael Fisher has replaced the conventional stage floor with two huge moveable performance platforms and five smaller platforms that appear to float above a gigantic pit descending 51 feet below floor level. One of the larger platforms is a tatami floor that moves backwards and forwards, the other platform is described by the New York Times as being the most thrilling performer in the show.The most consistently thrilling performer, perhaps appropriately, isn't even human: It's the giant slab of machinery that serves as one of the two stages designed by Mark Fisher. Here Mr. Lepage's ability to use a single emblem or image for a variety of dramatic purposes is magnified to epic proportions. Rising and falling with amazing speed and ease, spinning and tilting to a full vertical position, this huge, hydraulically powered game board is a sandy beach in one segment, a sheer cliff wall in another and a battleground, viewed from above, for the evening's exuberantly cinematic climax. (Isherwood)In the climax a vertical battle is fought by aerialists fighting up and down the surface of the sand stone cliff with defeated fighters portrayed as tumbling down the surface of the cliff into the depths of the pit below. Cirque du Soleil’s production entitled O, which phonetically is the French word eau meaning water, is a collaboration with director Franco Dragone that has been running at Las Vegas’ Bellagio Hotel since 1998. O has grossed over a billion dollars since it opened in 1998 (Sylt and Reid). It is an aquatic circus or an aquadrama. In 1804, Charles Dibdin, one of Astley’s rivals, taking advantage of the nearby New River, “added to the accoutrements of the Sadler’s Wells Theatre a tank three feet deep, ninety feet long and as wide as twenty-four feet which could be filled with water from the New River” (Hays and Nickolopoulou 171) Sadler’s Wells presented aquadramas depicting many reconstructions of famous naval battles. One of the first of these was The Siege of Gibraltar (1804) that used “117 ships designed by the Woolwich Dockyard shipwrights and capable of firing their guns” (Hays and Nickolopoulou 5). To represent the drowning Spanish sailors saved by the British, “Dibdin used children, ‘who were seen swimming and affecting to struggle with the waves’”(5).O (1998) is the first Cirque production to be performed in a proscenium arch theatre, with the pool installed behind the proscenium arch. “To light the water in the pool, a majority of the front lighting comes from a subterranean light tunnel (at the same level as the pool) which has eleven 4" thick Plexiglas windows that open along the downstage perimeter of the pool” (Lampert-Greaux). Accompanied by a live orchestra, performers dive into the 53 x 90 foot pool from on high, they swim underwater lit by lights installed in the subterranean light tunnel and they also perform on perforated platforms that rise up out of the water and turn the pool into a solid stage floor. In many respects, Cirque du Soleil can be seen to be the inheritors of the spectacular illegitimate circus of the 18th and 19th Century. The inheritance can be seen in Cirque du Soleil’s entrepreneurial daring, the corporeal dramaturgy privileging the affective power of the body over the use of words, in the performers presented primarily as character bodies, and in the delivering of essential text either as a prologue or as lyrics to songs. It can also be seen in Cirque du Soleil’s innovative staging design, the uptake of military based technology and the experimentation with cutting edge visual effects. Although re-invigorating the tradition and creating spectacular shows that in many respects are entirely of the moment, Cirque du Soleil’s aesthetic roots can be clearly seen to draw deeply on the inheritance of illegitimate circus.ReferencesBratton, Jacky. “Romantic Melodrama.” The Cambridge Companion to British Theatre 1730-1830. Eds. Jane Moody and Daniel O'Quinn. Cambridge: Cambridge University, 2007. 115-27. Bratton, Jacky. “What Is a Play? Drama and the Victorian Circus in the Performing Century.” Nineteenth-Century Theatre’s History. Eds. Tracey C. Davis and Peter Holland. Hampshire, UK: Palgrave Macmillan, 2007. 250-62.Cavendish, Richard. “Death of Madame Tussaud.” History Today 50.4 (2000). 15 Aug. 2014 ‹http://www.historytoday.com/richard-cavendish/death-madame-tussaud›.Cirque du Soleil. 2014. 10 Sep. 2014 ‹http://www.cirquedusoleil.com/en/home/about-us/at-a-glance.aspx›.Davis, Janet M. The Circus Age: Culture and Society under the American Big Top. Chapel Hill and London: University of North Carolina Press, 2002. Hays, Michael, and Anastasia Nikolopoulou. Melodrama: The Cultural Emergence of a Genre. New York: Palgrave Macmillan, 1999.House of Dancing Water. 2014. 17 Aug. 2014 ‹http://thehouseofdancingwater.com/en/›.Isherwood, Charles. “Fire, Acrobatics and Most of All Hydraulics.” New York Times 5 Feb. 2005. 12 Sep. 2014 ‹http://www.nytimes.com/2005/02/05/theater/reviews/05cirq.html?_r=0›.Fink, Jerry. “Cirque du Soleil Spares No Cost with Kà.” Las Vegas Sun 2004. 17 Sep. 2014 ‹http://www.lasvegassun.com/news/2004/sep/16/cirque-du-soleil-spares-no-cost-with-ka/›.Fricker, Karen. “Le Goût du Risque: Kà de Robert Lepage et du Cirque du Soleil.” (“Risky Business: Robert Lepage and the Cirque du Soleil’s Kà.”) L’Annuaire théâtral 45 (2010) 45-68. Trans. Isabelle Savoie. (Original English Version not paginated.)Hurley, Erin. "Les Corps Multiples du Cirque du Soleil." Globe: Revue Internationale d’Études Quebecoise. Les Arts de la Scene au Quebec, 11.2 (2008). (Original English n.p.)Jacob, Pascal. The Circus Artist Today: Analysis of the Key Competences. Brussels: FEDEC: European Federation of Professional Circus Schools, 2008. 5 June 2010 ‹http://sideshow-circusmagazine.com/research/downloads/circus-artist-today-analysis-key-competencies›.Jando, Dominique. “Philip Astley, Circus Owner, Equestrian.” Circopedia. 15 Sep. 2014 ‹http://www.circopedia.org/Philip_Astley›.Kwint, Marius. “The Legitimization of Circus in Late Georgian England.” Past and Present 174 (2002): 72-115.---. “The Circus and Nature in Late Georgian England.” Histories of Leisure. Ed. Rudy Koshar. Oxford: Berg Publishers, 2002. 45-60. ---. “The Theatre of War.” History Today 53.6 (2003). 28 Mar. 2012 ‹http://www.historytoday.com/marius-kwint/theatre-war›.Lampert-Greaux, Ellen. “The Wizardry of O: Cirque du Soleil Takes the Plunge into an Underwater World.” livedesignonline 1999. 17 Aug. 2014 ‹http://livedesignonline.com/mag/wizardry-o-cirque-du-soleil-takes-plunge-underwater-world›.Lavers, Katie. “Sighting Circus: Perceptions of Circus Phenomena Investigated through Diverse Bodies.” Doctoral Thesis. Perth, WA: Edith Cowan University, 2014. Leroux, Patrick Louis. “The Cirque du Soleil in Las Vegas: An American Striptease.” Revista Mexicana de Estudio Canadiens (Nueva Época) 16 (2008): 121-126.Mazza, Ed. “Cirque du Soleil’s Drone Video ‘Sparked’ is Pure Magic.” Huffington Post 22 Sep. 2014. 23 Sep. 2014 ‹http://www.huffingtonpost.com/2014/09/22/cirque-du-soleil-sparked-drone-video_n_5865668.html›.Meisel, Martin. Realizations: Narrative, Pictorial and Theatrical Arts in Nineteenth-Century England. Princeton, New Jersey: Princeton University Press, 1983.Moody, Jane. Illegitimate Theatre in London, 1770-1840. Cambridge: Cambridge University Press, 2000. O'Quinn, Daniel. Staging Governance: Teatrical Imperialism in London 1770-1800. Baltimore, Maryland, USA: Johns Hopkins University Press, 2005. O'Quinn, Daniel. “Theatre and Empire.” The Cambridge Companion to British Theatre 1730-1830. Eds. Jane Moody and Daniel O'Quinn. Cambridge: Cambridge University Press, 2007. 233-46. Reed, Peter P. “Interrogating Legitimacy in Britain and America.” The Oxford Handbook of Georgian Theatre. Eds. Julia Swindells and Francis David. Oxford: Oxford University Press, 2014. 247-264.Saxon, A.H. “The Circus as Theatre: Astley’s and Its Actors in the Age of Romanticism.” Educational Theatre Journal 27.3 (1975): 299-312.Schlicke, P. Dickens and Popular Entertainment. London: Unwin Hyman, 1985.St. Leon, Mark. Circus: The Australian Story. Melbourne: Melbourne Books, 2011. Stoddart, Helen. Rings of Desire: Circus History and Representation. Manchester: Manchester University Press, 2000. Swed, Mark. “Epic, Extravagant: In Ka the Acrobatics and Dazzling Special Effects Are Stunning and Enchanting.” Los Angeles Times 5 Feb. 2005. 22 Aug. 2014 ‹http://articles.latimes.com/2005/feb/05/entertainment/et-ka5›.Sylt, Cristian, and Caroline Reid. “Cirque du Soleil Swings to $1bn Revenue as It Mulls Shows at O2.” The Independent Oct. 2011. 14 Sep. 2014 ‹http://www.independent.co.uk/news/business/news/cirque-du-soleil-swings-to-1bn-revenue-as-it-mulls-shows-at-o2-2191850.html›.Tait, Peta. Circus Bodies: Cultural Identity in Aerial Performance. London: Routledge, 2005.Terdiman, Daniel. “Flying Lampshades: Cirque du Soleil Plays with Drones.” CNet 2014. 22 Sept 2014 ‹http://www.cnet.com/news/flying-lampshades-the-cirque-du-soleil-plays-with-drones/›.Venables, Michael. “The Technology Behind the Las Vegas Magic of Cirque du Soleil.” Forbes Magazine 30 Aug. 2013. 16 Aug. 2014 ‹http://www.forbes.com/sites/michaelvenables/2013/08/30/technology-behind-the-magical-universe-of-cirque-du-soleil-part-one/›.

Photograph by Gonzalo Echeverria (2010)The Screen would light up. They would feel a thrill of satisfaction. But the colours had faded with age, the picture wobbled on the screen, the women were of another age; they would come out they would be sad. It was not the film they had dreamt of. It was not the total film each of them had inside himself, the perfect film they could have enjoyed forever and ever. The film they would have liked to make. Or, more secretly, no doubt, the film they would have liked to live. (Perec 57) Over the years that I have watched and thought about Jean-Luc Godard’s films I have been struck by the idea of him as an artist who works with the moving image and perhaps just as importantly the idea of cinema as an irresolvable series of problems. Most obviously this ‘problematic condition’ of Godard’s practice is evidenced in the series of crises and renunciations that pepper the historical trace of his work. A trace that is often characterised thus: criticism, the Nouvelle Vague, May 1968, the Dziga Vertov group, the adoption of video, the return to narrative form, etc. etc. Of all these events it is the rejection of both the dominant cinematic narrative form and its attendant models of production that so clearly indicated the depth and intensity of Godard’s doubt in the artistic viability of the institution of cinema. Historically and ideologically congruent with the events of May 1968, this turning away from tradition was foreshadowed by the closing titles of his 1967 opus Week End: fin de cinema (the end of cinema). Godard’s relentless application to the task of engaging a more discursive and politically informed mode of operation had implications not only for the films that were made in the wake of his disavowal of cinema but also for those that preceded it. In writing this paper it was my initial intention to selectively consider the vast oeuvre of the filmmaker as a type of conceptual project that has in some way been defined by the condition of doubt. While to certain degree I have followed this remit, I have found it necessary to focus on a small number of historically correspondent filmic instances to make my point. The sheer size and complexity of Godard’s output would effectively doom any other approach to deal in generalities. To this end I am interested in the ways that these films have embodied doubt as both an aesthetic and philosophical position. There is an enduring sense of contentiousness that surrounds both the work and perceived motives of the filmmaker Jean-Luc Godard that has never come at the cost of discourse. Through a period of activity that now stretches into its sixth decade Godard has shaped an oeuvre that is as stylistically diverse as it is theoretically challenging. This span of practice is noteworthy not only for its sheer length but for its enduring ability to polarise both audiences and critical opinion. Indeed these opposing critical positions are so well inscribed in our historical understanding of Godard’s practice that they function as a type of secondary narrative. It is a narrative that the artist himself has been more than happy to cultivate and at times even engage. One hardly needs to be reminded that Godard came to making films as a critic. He asserted in the pages of his former employer Cahiers du Cinema in 1962 that “As a critic, I thought of myself as a filmmaker. Today I still think of myself as a critic, and in a sense I am, more than ever before. Instead of writing criticism, I make a film, but the critical dimension is subsumed” (59). If Godard did at this point in time believe that the criticality of practice as a filmmaker was “subsumed”, the ensuing years would see a more overt sense of criticality emerge in his work. By 1968 he was to largely reject both traditional cinematic form and production models in a concerted effort to explore the possibilities of a revolutionary cinema. In the same interview the director went on to extol the virtues of the cine-literacy that to a large part defined the loose alignment of Nouvelle Vague directors (Chabrol, Godard, Rohmer, Rivette, Truffaut) referred to as the Cahiers group claiming that “We were the first directors to know that Griffiths exists” (Godard 60). It is a statement that is as persuasive as it is dramatic, foregrounding the hitherto obscured history of cinema while positioning the group firmly within its master narrative. However, given the benefit of hindsight one realises that perhaps the filmmaker’s motives were not as simple as historical posturing. For Godard what is at stake is not just the history of cinema but cinema itself. When he states that “We were thinking cinema and at a certain moment we felt the need to extend that thought” one is struck by how far and for how long he has continued to think about and through cinema. In spite of the hours of strict ideological orthodoxy that accompanied his most politically informed works of the late 1960s and early 1970s or the sustained sense of wilful obtuseness that permeates his most “difficult” work, there is a sense of commitment to extending “that thought” that is without peer. The name “Godard”, in the words of the late critic Serge Daney, “designates an auteur but it is also synonymous with a tenacious passion for that region of the world of images we call the cinema” (Daney 68). It is a passion that is both the crux of his practice as an artist and the source of a restless experimentation and interrogation of the moving image. For Godard the passion of cinema is one that verges on religiosity. This carries with it all the philosophical and spiritual implications that the term implies. Cinema functions here as a system of signs that at once allows us to make sense of and live in the world. But this is a faith for Godard that is nothing if not tested. From the radical formal experimentation of his first feature film À Bout de soufflé (Breathless) onwards Godard has sought to place the idea of cinema in doubt. In this sense doubt becomes a type of critical engine that at once informs the shape of individual works and animates the constantly shifting positions the artist has occupied. Serge Daney's characterisation of the Nouvelle Vague as possessed of a “lucidity tinged with nostalgia” (70) is especially pertinent in understanding the way in which doubt came to animate Godard’s practice across the 1960s and beyond. Daney’s contention that the movement was both essentially nostalgic and saturated with an acute awareness that the past could not be recreated, casts the cinema itself as type of irresolvable proposition. Across the dazzling arc of films (15 features in 8 years) that Godard produced prior to his renunciation of narrative cinematic form in 1967, one can trace an unravelling of faith. During this period we can consider Godard's work and its increasingly complex engagement with the political as being predicated by the condition of doubt. The idea of the cinema as an industrial and social force increasingly permeates this work. For Godard the cinema becomes a site of questioning and ultimately reinvention. In his 1963 short film Le Grand Escroc (The Great Rogue) a character asserts that “cinema is the most beautiful fraud in the world”. Indeed it is this sense of the paradoxical that shadows much of his work. The binary of beauty and fraud, like that of faith and doubt, calls forth a questioning of the cinema that stands to this day. It is of no small consequence that so many of Godard’s 1960s works contain scenes of people watching films within the confines of a movie theatre. For Godard and his Nouvelle Vague peers the sale de cinema was both the hallowed site of cinematic reception and the terrain of the everyday. It is perhaps not surprising then he chooses the movie theatre as a site to play out some of his most profound engagements with the cinema. Considered in relation to each other these scenes of cinematic viewing trace a narrative in which an undeniable affection for the cinema is undercut by both a sense of loss and doubt. Perhaps the most famous of Godard’s ‘viewing’ scenes is from the film Vivre Sa Vie (My Life to Live). Essentially a tale of existential trauma, the film follows the downward spiral of a young woman Nana (played by Anna Karina) into prostitution and then death at the hands of ruthless pimps. Championed (with qualifications) by Susan Sontag as a “perfect film” (207), it garnered just as many detractors, including famously the director Roberto Rosellini, for what was perceived to be its nihilistic content and overly stylised form. Seeking refuge in a cinema after being cast out from her apartment for non payment of rent the increasingly desperate Nana is shown engrossed in the starkly silent images of Carl Dreyer’s 1928 film La Passion de Jeanne d’Arc (The Passion of Joan of Arc). Godard cuts from the action of his film to quote at length from Dreyer’s classic, returning from the mute intensity of Maria Faloconetti’s portrayal of the condemned Joan of Arc to Karina’s enraptured face. As Falconetti’s tears swell and fall so do Karina’s, the emotional rawness of the performance on the screen mirrored and internalised by the doomed character of Nana. Nana’s identification with that of the screen heroine is at once total and immaculate as her own brutal death at the hands of men is foretold. There is an ominous silence to this sequence that serves not only to foreground the sheer visual intensity of what is being shown but also to separate it from the world outside this purely cinematic space. However, if we are to read this scene as a testament to the power of the cinematic we must also admit to the doubt that resides within it. Godard’s act of separation invites us to consider the scene not only as a meditation on the emotional and existential state of the character of Nana but also on the foreshortened possibilities of the cinema itself. As Godard’s shots mirror those of Dreyer we are presented with a consummate portrait of irrevocable loss. This is a complex system of imagery that places Dreyer’s faith against Godard’s doubt without care for the possibility of resolution. Of all Godard’s 1960s films that feature cinema spectatorship the sequence belonging to Masculin Féminin (Masculine Feminine) from 1966 is perhaps the most confounding and certainly the most digressive. A series of events largely driven by a single character’s inability or unwillingness to surrender to the projected image serve to frustrate, fracture and complexify the cinema-viewing experience. It is however, a viewing experience that articulates the depth of Godard’s doubt in the viability of the cinematic form. The sequence, like much of the film itself, centres on the trials of the character Paul played by Jean-Pierre Léaud. Locked in a struggle against the pop-cultural currents of the day and the attendant culture of consumption and appearances, Paul is positioned within the film as a somewhat conflicted and ultimately doomed romantic. His relationship with Madeleine played by real life yé-yé singer Chantal Goya is a source of constant anxiety. The world that he inhabits, however marginally, of nightclubs, pop records and publicity seems philosophically at odds with the classical music and literature that he avidly devours. If the cinema-viewing scene of Vivre Sa Vie is defined by the enraptured intensity of Anna Karina’s gaze, the corresponding scene in Masculin Féminin stands, at least initially, as the very model of distracted spectatorship. As the film in the theatre starts, Paul who has been squeezed out of his seat next to Madeleine by her jealous girlfriend, declares that he needs to go to the toilet. On entering the bathroom he is confronted by the sight of a pair of men locked in a passionate kiss. It is a strange and disarming turn of events that prompts his hastily composed graffiti response: down with the republic of cowards. For theorist Nicole Brenez the appearance of these male lovers “is practically a fantasmatic image evoked by the amorous situation that Paul is experiencing” (Brenez 174). This quasi-spectral appearance of embracing lovers and grafitti writing is echoed in the following sequence where Paul once again leaves the theatre, this time to fervently inform the largely indifferent theatre projectionist about the correct projection ratio of the film being shown. On his graffiti strewn journey back inside Paul encounters an embracing man and woman nestled in an outer corner of the theatre building. Silent and motionless the presence of this intertwined couple is at once unsettling and prescient providing “a background real for what is being projected inside on the screen” (Brenez 174). On returning to the theatre Paul asks Madeleine to fill him in on what he has missed to which she replies, “It is about a man and woman in a foreign city who…”. Shot in Stockholm to appease the Swedish co-producers that stipulated that part of the production be made in Sweden, the film within a film occupies a fine line between restrained formal artfulness and pornographic violence. What could have been a creatively stifling demand on the part of his financial backers was inverted by Godard to become a complex exploration of power relations played out through an unsettling sexual encounter. When questioned on set by a Swedish television reporter what the film was about the filmmaker curtly replied, “The film has a lot to do with sex and the Swedish are known for that” (Masculin Féminin). The film possesses a barely concealed undertow of violence. A drama of resistance and submission is played out within the confines of a starkly decorated apartment. The apartment itself is a zone in which language ceases to operate or at the least is reduced to its barest components. The man’s imploring grunts are met with the woman’s repeated reply of “no”. What seemingly begins as a homage to the contemporaneous work of Swedish director Ingmar Bergman quickly slides into a chronicle of coercion. As the final scene of seduction/debasement is played out on the screen the camera pulls away to reveal the captivated gazes of Madeleine and her friends. It finally rests on Paul who then shuts his eyes, unable to bear what is being shown on the screen. It is a moment of refusal that marks a turning away not only from this projected image but from cinema itself. A point made all the clearer by Paul’s voiceover that accompanies the scene: We went to the movies often. The screen would light up and we would feel a thrill. But Madeleine and I were usually disappointed. The images were dated and jumpy. Marilyn Monroe had aged badly. We felt sad. It wasn't the movie of our dreams. It wasn't that total film we carried inside ourselves. That film we would have liked to make. Or, more secretly, no doubt the film we wanted to live. (Masculin Féminin) There was a dogged relentlessness to Godard’s interrogation of the cinema through the very space of its display. 1963’s Le Mépris (Contempt) swapped the public movie theatre for the private screening room; a theatrette emblazoned with the words Il cinema é un’invenzione senza avvenire. The phrase, presented in a style that recalled Soviet revolutionary graphics, is an Italian translation of Louis Lumiere’s 1895 appraisal of his new creation: “The cinema is an invention without a future.” The words have an almost physical presence in the space providing a fatalistic backdrop to the ensuing scene of conflict and commerce. As an exercise in self reflexivity it at once serves to remind us that even at its inception the cinema was cast in doubt. In Le Mépris the pleasures of spectatorship are played against the commercial demands of the cinema as industry. Following a screening of rushes for a troubled production of Homer’s Odyssey a tempestuous exchange ensues between a hot-headed producer (Jeremy Prokosch played by Jack Palance) and a calmly philosophical director (Fritz Lang as himself). It is a scene that attests to Godard’s view of the cinema as an art form that is creatively compromised by its own modes of production. In a film that plays the disintegration of a relationship against the production of a movie and that features a cast of Germans, Italians and French it is of no small consequence that the movie producer is played by an American. An American who, when faced with a creative impasse, utters the phrase “when I hear the word culture I bring out my checkbook”. It is one of Godard’s most acerbic and doubt filled sequences pitting as he does the implied genius of Lang against the tantrum throwing demands of the rapacious movie producer. We are presented with a model of industrial relations that is both creatively stifling and practically unworkable. Certainly it was no coincidence that Le Mépris had the biggest budget ($1 million) that Godard has ever worked with. In Godard’s 1965 film Une Femme Mariée (A Married Woman), he would once again use the movie theatre as a location. The film, which dealt with the philosophical implications of an adulterous affair, is also notable for its examination of the Holocaust and that defining event’s relationship to personal and collective memory. Biographer Richard Brody has observed that, “Godard introduced the Auschwitz trial into The Married Woman (sic) as a way of inserting his view of another sort of forgetting that he suggested had taken hold of France—the conjoined failures of historical and personal memory that resulted from the world of mass media and the ideology of gratification” (Brody 196-7). Whatever the causes, there is a pervading sense of amnesia that surrounds the Holocaust in the film. In one exchange the character of Charlotte, the married woman in question, momentarily confuses Auschwitz with thalidomide going on to later exclaim that “the past isn’t fun”. But like the barely repressed memories of her past indiscretions, the Holocaust returns at the most unexpected juncture in the film. In what starts out as Godard’s most overt reference to the work of Alfred Hitchcock, Charlotte and her lover secretly meet under the cover of darkness in a movie theatre. Each arriving separately and kitted out in dark sunglasses, there is breezy energy to this clandestine rendezvous highly reminiscent of the work of the great director. It is a stylistic point that is underscored in the film by the inclusion of a full-frame shot of Hitchcock’s portrait in the theatre’s foyer. However, as the lovers embrace the curtain rises on Alain Resnais’s 1955 documentary Nuit et Brouillard (Night and Fog). The screen is filled with images of barbed wire as the voice of narrator Jean Cayrol informs the audience that “even a vacation village with a fair and a steeple can lead very simply to a concentration camp.” It is an incredibly shocking moment, in which the repressed returns to confirm that while memory “isn’t fun”, it is indeed necessary. An uncanny sense of recognition pervades the scene as the two lovers are faced with the horrendous evidence of a past that refuses to stay subsumed. The scene is all the more powerful for the seemingly casual manner it is relayed. There is no suspenseful unveiling or affected gauging of the viewers’ reactions. What is simply is. In this moment of recognition the Hitchcockian mood of the anticipation of an illicit rendezvous is supplanted by a numbness as swift as it is complete. Needless to say the couple make a swift retreat from the now forever compromised space of the theatre. Indeed this scene is one of the most complex and historically layered of any that Godard had produced up to this point in his career. By making overt reference to Hitchcock he intimates that the cinema itself is deeply implicated in this perceived crisis of memory. What begins as a homage to the work of one of the most valorised influences of the Nouvelle Vague ends as a doubt filled meditation on the shortcomings of a system of representation. The question stands: how do we remember through the cinema? In this regard the scene signposts a line of investigation that would become a defining obsession of Godard’s expansive Histoire(s) du cinéma, a project that was to occupy him throughout the 1990s. Across four chapters and four and half hours Histoire(s) du cinéma examines the inextricable relationship between the history of the twentieth century and the cinema. Comprised almost completely of filmic quotations, images and text, the work employs a video-based visual language that unremittingly layers image upon image to dissolve and realign the past. In the words of theorist Junji Hori “Godard's historiography in Histoire(s) du cinéma is based principally on the concept of montage in his idiosyncratic sense of the term” (336). In identifying montage as the key strategy in Histoire(s) du cinéma Hori implicates the cinema itself as central to both Godard’s process of retelling history and remembering it. However, it is a process of remembering that is essentially compromised. Just as the relationship of the cinema to the Holocaust is bought into question in Une Femme Mariée, so too it becomes a central concern of Histoire(s) du cinéma. It is Godard’s assertion “that the cinema failed to honour its ethical commitment to presenting the unthinkable barbarity of the Nazi extermination camps” (Temple 332). This was a failure that for Godard moved beyond the realm of doubt to represent “nothing less than the end of cinema” (Brody 512). In October 1976 the New Yorker magazine published a profile of Jean Luc Godard by Penelope Gilliatt a writer who shared the post of film critic at the magazine with Pauline Kael. The article was based on an interview that took place at Godard’s production studio in Grenoble Switzerland. It was notable for two things: Namely, the most succinct statement that Godard has made regarding the enduring sense of criticality that pervades his work: “A good film is a matter of questions properly put.” (74) And secondly, surely the shortest sentence ever written about the filmmaker: “Doubt stands.” (77)ReferencesÀ Bout de soufflé. Dir. Jean Luc Godard. 1960. DVD. Criterion, 2007. Brenez, Nicole. “The Forms of the Question.” For Ever Godard. Eds. Michael Temple, James S. Williams, and Michael Witt. London: Black Dog, 2004. Brody, Richard. Everything Is Cinema: The Working Life of Jean-Luc Godard. New York: Metropolitan Books / Henry Holt & Co., 2008. Daney, Serge. “The Godard Paradox.” For Ever Godard. Eds. Michael Temple, James S. Williams, and Michael Witt. London: Black Dog, 2004. Gilliat, Penelope. “The Urgent Whisper.” Jean-Luc Godard Interviews. Ed. David Sterritt. Jackson: University Press of Mississippi, 1998. Godard, Jean-Luc. “Jean-Luc Godard: 'From Critic to Film-Maker': Godard in Interview (extracts). ('Entretien', Cahiers du Cinema 138, December 1962).” Cahiers du Cinéma: 1960-1968 New Wave, New Cinema, Reevaluating Hollywood. Ed. Jim Hillier. Cambridge, Mass.: Harvard University Press, 1986. Histoires du Cinema. Dir. and writ. Jean Luc Godard. 1988-98. DVD, Artificial Eye, 2008. Hori, Junji. “Godard’s Two Histiographies.” For Ever Godard. Eds. Michael Temple, James S. Williams, and Michael Witt. London: Black Dog, 2004. Le Grand Escroc. Dir. Jean Luc Godard. Perf. Jean Seberg. Film. Ulysse Productions, 1963. Le Mépris. Dir. Jean Luc Godard. Perf. Jack Palance, Fritz Lang. 1964. DVD. Criterion, 2002. La Passion de Jeanne d’Arc. Dir. Carl Theodor Dreyer. Film. Janus films, 1928. MacCabe, Colin. Godard: A Portrait of the Artist at 70. London: Bloomsbury, 2003. Masculin Féminin. Dir. and writ. Jean Luc Godard. Perf. Jean-Pierre Léaud. 1966. DVD. Criterion, 2005. Nuit et Brouillard. Dir Alain Resnais. Film. Janus Films, 1958. Perec, Georges. Things: A Story of the Sixties. Trans. David Bellos. London: Collins Harvill, 1990. (Originally published 1965.) Sontag, Susan. “Godard’s Vivre Sa Vie.” Against Interpretation and Other Essays. New York: Picador, 2001. Temple, Michael, James S. Williams, and Michael Witt, eds. For Ever Godard. London: Black Dog, 2004. Une Femme Mariée. Dir. and writ. Jean Luc Godard. Perf. Macha Meril. 1964. DVD. Eureka, 2009. Vivre Sa Vie. Dir. and writ. Jean Luc Godard. Perf. Anna Karina. 1962. DVD. Criterion, 2005. Week End, Dir. and writ. Jean Luc Godard. 1967. DVD. Distinction Series, 2005.

Photo by Jeremy Wong on Unsplash ABSTRACT In response to the threat of COVID-19, CMS issued unprecedented restrictions severely limiting the liberty of older adults residing in long-term care. Older adults are identified as at a high risk of becoming infected through exposure to SARS-Cov-2 and of suffering the most severe morbidity and mortality. While protecting the individual from disease, the restrictions also had a determinantal effect. The restrictions exacerbated social isolation and loneliness, two pervasive public health concerns within the older adult population. Legally, the restrictions pass constitutional muster. The ethical analysis presents more questions and debates. Initially, the restrictions to protect the older adult were grounded in public health ethics and bioethics principles. However, the ethical lines become blurred as the risk of harm secondary to isolation increased over the time that the restrictions remained in effect. The ethical point of view becomes more divergent considering the restrictions also preserved medical resources for the greater good of society, arguably diverting them to serve younger people. We have a moral obligation to reduce social isolation and recognize the older adult as a valuable member of society with equal worth and dignity. INTRODUCTION In response to the threat of COVID-19, CMS issued unprecedented restrictions severely limiting the liberty of older adults residing in long-term care. Older adults are identified as at a high risk of becoming infected from exposure to SARS-Cov-2 and from suffering the most severe morbidity and mortality. While protecting the individual from disease, the restrictions also had a determinantal effect. The restrictions exacerbated social isolation and loneliness, two pervasive public health concerns within the older adult population. Legally, the restrictions pass Constitutional muster. The ethical analysis presents more questions and debates. Initially, the restrictions to protect the older adult were grounded in public health ethics and bioethics principles. However, the ethical lines become blurred as the risk of harm secondary to isolation increased over the time that the restrictions remained in effect. The devastation of COVID-19 within the older adult population extends beyond the immediate risk and harm of infection. At the beginning of the COVID-19 pandemic, experts determined that older adults, especially those living in long-term care, were at a greater risk of becoming infected and depleting scarce medical resources. Two days after WHO declared the pandemic, the Centers for Medicare & Medicaid Services (CMS) followed the Centers for Disease Control (CDC) recommendations and announced mitigation measures that required long-term care facilities to (1) restrict volunteers and nonessential personnel from entering the facility; (2) cancel all group activities and communal dining; (3) screen residents and health care personnel for fever and respiratory symptoms; and (4) encourage residents to stay in their rooms. The social isolation resulting from the mitigation measures posed a credible threat to five core domains of healthy aging: (1) promoting health; preventing injury and managing chronic conditions; (2) cognitive health; (3) physical health; (4) mental health; and (5) facilitating social engagement.[1] l. Social Isolation and Loneliness COVID-19 highlighted two pervasive public health concerns confronting older adults—social isolation and loneliness. Social isolation is an objective deficit in the number of relationships and the frequency of contact with family, friends, and the community.[2] Social Isolation is a risk factor for loneliness. Loneliness is the subjective perception of a lack of meaningful relationships.[3] Loneliness has three dimensions: (1) absence of a significant person to provide emotional support and affirm one’s value as a person; (2) absence of a small group of people seen regularly, such as a card group; and (3) absence of a larger network group of people who provide support by being together as a group, for example, church services or rotary meetings.[4] COVID-19 restrictions affected all three dimensions. Social isolation can be as dangerous as smoking fifteen cigarettes per day, earning its designation as a public health priority.[5] Isolation increases the risk of cardiovascular disease, obesity, anxiety, and depression. Loneliness can lead to depression, alcoholism, and suicidal thoughts.[6] Some studies found that loneliness is also a factor in cognitive decline. For example, caregivers reported that 63 percent of older adults with cognitive impairment experienced cognitive decline during the COVID-19 pandemic.[7] In 2017, the American Association of Retired Persons (AARP) reported that social isolation accounted for $6.7 billion in additional Medicare spending although only 14 percent of older adults in the US reported being socially isolated.[8] Approximately 24 percent of community-dwelling older adults in the US are socially isolated. Forty-three percent of adults aged 60 and older report feeling lonely. Those living in long-term care report loneliness at a rate of at least double of community-dwelling older adults.[9] WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”[10] A broad definition of health highlights the detriment of social isolation in older adults. There is a moral obligation to mitigate the effect of isolation.[11] The additional Medicare spending costs attributable to the effects of social isolation secondary to COVID-19 will be extraordinary. Providing social support will directly benefit older adults and indirectly benefit society by reducing Medicare spending associated with the effects of social isolation. Combating the pervasiveness of social isolation requires immediate collaborative community action. Many long-term care residents who depend on visits from family and friends to socialize increasingly felt lonely, abandoned, and despondent,[12] increasing the risk of feeling grief and loss, including individual and collective trauma reactions.[13] Also, normally social opportunities, medical, and legal appointments defaulted to telephone or virtual appointments. The cessation of in-person medical appointments interfered with optimal management of chronic conditions and preventive care. Some older adults lack access to the technology, are unfamiliar with technology, or cannot use technology for other reasons. At least one study supports the potential for older adults to benefit from technology and suggests that training could promote long-term benefits in older adults aged 80 years and over.[14] Focusing on technological advances specific to older adults with input from older adults should be a priority. When communal dining abruptly stopped, residents had to eat all their meals alone in their rooms. Older adults often mention the difficulty of eating meals alone, especially if recently divorced, widowed, or otherwise separated from a spouse or partner. Closure of the exercise facilities limited the ability of an older adult to stay physically active. Reduced physical activity creates long-term adverse health effects.[15] ll. Measures to Mitigate Isolation To facilitate some contact, long-term care facilities devised window visits. The resident remained safely inside the locked facility, standing or seated in front of a window. Visitors stood outside in the grass or parking lot. Any conversation took place over the telephone. To simulate physical contact, residents and visitors pressed their palms together, separated by the glass barrier. The window visits recall the prison visits depicted in movies and television. In late June 2020, CMS relaxed the restrictions and advised that long-term care facilities could resume some communal activities and permit outdoor visits. Although CMS eased the restrictions, interpersonal contact remained minimal. Outdoor visits required scheduling an appointment during limited hours of availability. The facilities limited the visits per week and the duration of each visit to thirty minutes. In addition, the staff enforced wearing personal protective equipment and maintaining physical distancing. Several impracticalities diminished the optimism of the relaxed restrictions. Residents could leave their rooms for meals but remained physically separated at a distance that prevented any meaningful interaction. Similarly, the limitations on the in-person visits presented problems. Non-resident spouses with mobility challenges found the outdoor access difficult, if not impossible. Residents or spouses with hearing and vision losses experienced challenges in communicating while sitting outside, six feet apart, and wearing masks.[16] lll. Legal Precedent for Emergency Measures The primary legal issue stems from the conflict between individual liberty and the public good or health. Jacobson v. Massachusetts provides a framework for balancing individual liberty rights and the public good during a pandemic.[17] Jacobson clarified an essential point of law - the rights and liberties secured by the US Constitution are not absolute.[18] Faced with a pandemic, a community has the right to protect members of the community.[19] Jacobson outlines four standards for imposing public health mandates during a pandemic. First, the State overreaches when it uses public health powers unnecessarily.[20] Second, the state must use the least restrictive means to prevent harm.[21] Third, the state must use reasonable means expected to prevent or ameliorate a health threat.[22] Finally, the intervention must not pose an undue risk.[23] The guidelines in Jacobson, established during the smallpox pandemic, apply to COVID-19. In response to the threat of COVID-19, public health authorities enacted mandates to protect the public, especially older adults, against the highly contagious and virulent virus. The CMS restrictions specifically addressed older adults living in long-term care facilities. While the CMS directives obstructed residents’ liberties, they also contradicted the Assisted Living Facility social model, which places autonomy and independence at the forefront. Given the gravity of harm and the uncertainties in the early phases of the pandemic, the restrictions were arguably the least restrictive means to manage the immediate threat. The effectiveness varied from facility to facility, with many deaths throughout the US in long-term care facilities. While valuable early in the pandemic, at some point the continuation of the mitigation measures increased social isolation and its associated risks. In Jew Ho v. Williamson, the Supreme Court overturned a quarantine order to contain the bubonic plague.[24] The officials enforced the order only against a targeted ethnic population which did not present an identified risk.[25] In reaching its decision, the Court determined that the quarantine order was not a reasonable regulation to prevent the spread of the bubonic plague. Rather, it was racially motivated. The Court ruled that the government cannot impose public health orders in a racially invidious manner.[26] There are similarities between Jew Ho and the CMS restrictions. Like the quarantine order in Jew Ho, the restrictions targeted a specific population. But with COVID-19 older adults were an identified high-risk population because of their susceptibility to infection and severe illness. During the early phases of the pandemic, the directives were reasonable to accomplish the purpose of preventing the spread in the identified high-risk population. They were not discriminatory according to the rule of law in Jew Ho. The argument supporting the constitutionality of the CMS restrictions wanes as the length of the safety precautions increased. lV. Ethical Analysis of the Lengthy Social Isolation The CMS restrictions require the ethical analysis of harm, proportionality, reciprocity, and transparency. As well as analysis under the principles of autonomy, beneficence, non-maleficence, and justice. a. Harm and Proportionality As previously discussed, older adult long-term care residents were more susceptible to COVID-19 and to severe physical effects requiring hospitalization. In addition, older adults are more likely to die from COVID-19. Based on a totality of the circumstances and what we knew about the virus in the early phases of the pandemic, the restrictions were the least restrictive means to protect this high-risk population. But the question of proportionality requires ongoing assessment and re-evaluation. While the initial uncertainty and chaos justified the restrictions, as the pandemic continued and the risk of harm from the restrictions increased, the pendulum began to swing. At some point, upon proof or likelihood of safety, less restrictive alternatives should have been adopted. b. Reciprocity The concept of reciprocity is a core principle of public health and requires the balancing of the benefits and burdens of the social cooperation.[27] When individuals sacrifice their liberty for the benefit of others, they should not be penalized as a result of making the sacrifice, and thus society owes a reciprocal obligation to the individuals, such as providing individuals support and not discriminating against them.[28] Residents did not have any input or choice when CMS and the administrators stripped away their autonomy and liberties. While the restrictions protected the individual resident from the direct harm of infection, the restrictions also protected society from the indirect harm of the depletion of scarce medical resources. Public health officials identified long-term care residents as most likely to require significant medical resources. One talking point repeatedly broadcast was the need to prevent the depletion of hospital beds, ventilators, medications, and supplies. Most assisted-living facilities are for-profit, and residents pay for their food, shelter, and personal needs. What does society owe these long-term care residents in return for the liberty they sacrificed for the benefit of society at large? At the very least, I suggest we owe these individuals the commitment to conduct research exploring and addressing the effects of the restrictions. c. Transparency by Government, the Media, and the Long-Term care Facilities The communications from government and public health officials about the pandemic and the restrictions were opaque, leaving unanswered questions, doubts, and speculation. Some facilities provided families with basic information communicated through robocall messaging, with words of encouragement, painting rosy pictures of the residents' sequestered daily lives. Public health officials assert the common good and protecting the public’s safety and health justify paternalism and compulsory powers.[29] One counterargument is that the compulsory interventions or restrictions push paternalism to new levels.[30] The COVID-19 pandemic and the mitigation interventions highlight this tension between libertarian and epidemiological models based on (1) shortages that triggered rationing and prioritization; and (2) measures that safeguarded public health but infringed on individual rights.[31] d. Autonomy, Beneficence, and Non-Maleficence Through a bioethical lens, we immediately see the clash between the CMS restrictions and the long-term care residents’ autonomy. However, autonomy is not absolute. There was a benefit for the individual resident: the protection from a deadly virus. Thus, I argue that the initial restrictions were beneficent. Yet I also point to the deleterious secondary physical and emotional effects of the isolation and assert that the restrictions should have been safely modified as new information on viral spread and safety came about. We can accept the beneficence of protecting the high-risk resident from a deadly disease while acknowledging the associated harm. However, at some point, we must also ask if the harm experienced due to prolonged severe restrictions reached a level that exceeded the boundaries of beneficence and became maleficent. Perceiving the long-term care resident as a passive recipient of care is paternalistic and antithetical to autonomy and a person-centered approach.[32] Instead, society must recognize older adults as essential stakeholders in policymaking. The direct and active involvement of older adults allows the individual to retain agency rather than becoming a passive recipient of care.[33] Prioritization of the older adult as an autonomous active participant counters ageism and promotes autonomy. e. Justice Justice calls for analysis of several discrepancies. First, the special protection of long-term care residents seems justifiable due to their special vulnerability. CMS treated long-term care facilities alike. Most community-dwelling older adults could decide whether to adhere to stay-at-home restrictions and were not subject to the same level of enforcement that existed within long-term care facilities. The restrictions were far more oppressive for long-term care residents. In response to the assertion that selective lockdown discriminates against older adults, the same arguments discussed above demonstrate the morally relevant justification: older adults are more likely to require hospitalization and die from COVID-19.[34] One convincing argument against restrictions on older adults echoing Kant’s categorical imperative argues that selectively restricting older adults for the good of other people amounts to treating older adults as a means to an end for others.[35] While the restrictions imposed on the individual might slow the spread of the disease within the specific long-term care facility, which protects that individual resident, they also impose on the individual resident to serve the greater good: the preservation of scarce medical resources. The second application pushes the restrictive measures closer to violating Kant’s categorical imperative by treating the older adult as a means to the end of others. That is, younger people and those living outside of long-term care would have more hospital resources available to them if long-term care residents were more severely isolated keeping them from needing hospitalization. From a Kantian perspective, the categorical imperative demands respecting the dignity of persons—Kant’s supreme (formal) principle.[36] When we consider the restrictions, I suggest that we must also consider the impact on dignity. It has been suggested that dignity is the “overarching principle of bioethics.”[37] In the context of an analysis of the socially isolating COVID-19 mitigation measures on older adults in long-term care facilities, we should consider the relational aspect of dignity, recognizing the adult as having value and equal worth. The protracted imposed isolation of older adults to preserve medical resources devalues older adults. Ongoing COVID-19 restrictions should be analyzed for their unjustified harms. A second justice concern outside the scope here is that long-term care facilities are resourced differently, and had different results due to quality of care, number of staff, infection control protocols, and previous health infraction records. CONCLUSION The myopic focus on mortality ignores the risks of morbidity secondary to the devastating effects of social isolation on the older adult’s health and quality of life. The paternalistic prevention eclipsed the resident’s autonomy. At some point, the attention and priority must shift. When formulating policies, we must figure out at what point or in which situations the negative impact of restrictions outweighs the protective benefits. Although the restrictions may have slowed the spread of COVID-19, we must not discount the negative consequences, which may be long-term. From an ethical perspective, we must acknowledge the harm that has occurred within this population and accept the responsibility to redress the harm and prevent repeating the mistakes. The prolonged restrictions stretched legal and ethical boundaries. The mixed purpose of the restrictions (protecting the individual resident and preserving healthcare resources) makes the ethical analysis more challenging. Yet doing something for someone’s own good is still paternalistic and problematic. The public health justification includes the collective. We must confront the tough questions about the efficacy of pandemic mitigation measures and the mitigation measures’ adverse consequences. Leaving the doors to long-term care facilities open during the pandemic would have exposed every resident and staff member to a contagion that presented a significant risk of morbidity and mortality. But locking the doors exacerbated social isolation and loneliness, increasing the risk of morbidity and mortality. Julian Savulescu may be correct that there was no desirable solution. We must still work to find better solutions that will reduce social isolation and recognize the older adult as a valuable member of society with equal worth and dignity. [1] Coronavirus Disease 2019 (COVID-19) Nursing Homes & Long-term care Facilities. (n.d.). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/index.html. [2]Escalante, E., Golden, R. L., & Mason, D. J. (2020). Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World. JAMA Health Forum, 1(12),e201597. https://doi.org/10.1001/jamahealthforum.2020.1597. [3] D'cruz, M., & Banerjee, D. (2020). ‘An invisible human rights crisis’: The marginalization of older adults during the COVID-19 pandemic – An advocacy review. Psychiatry Research, 292, 113369. https://doi.org/10.1016/j.psychres.2020.113369. [4] Simard, J., & Volicer, L. (2020). Loneliness and Isolation in Long-term care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), 966–967. https://doi.org/10.1016/j.jamda.2020.05.006. [5] Escalante, E., Golden, R. L., & Mason, D. J. (2020). Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World. JAMA Health Forum, 1(12). https://doi.org/10.1001/jamahealthforum.2020.1597. [6] Simard, J., & Volicer, L. (2020). Loneliness and Isolation in Long-term care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), 966–967. https://doi.org/10.1016/j.jamda.2020.05.006. [7] Batsis, J. A., Daniel, K., Eckstrom, E., Goldlist, K., Kusz, H., Lane, D., … Friedman, S. M. (2021, January 26). Promoting Healthy Aging During COVID‐19. American Geriatrics Society. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17035. [8] Escalante, E., Golden, R. L., & Mason, D. J. (2020). Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World. JAMA Health Forum, 1(12), e201597. https://doi.org/10.1001/jamahealthforum.2020.1597. [9] Simard, J., & Volicer, L. (2020). Loneliness and Isolation in Long-term care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), 966–967. https://doi.org/10.1016/j.jamda.2020.05.006. [10] World Health Organization. Frequently Asked Questions. https://www.who.int/about/frequently-asked-questions. [11] Chu, C. H., Donato‐Woodger, S., & Dainton, C. J. (2020). Competing crises: COVID‐19 countermeasures and social isolation among older adults in long‐term care. Journal of Advanced Nursing, 76(10), 2456–2459. https://doi.org/10.1111/jan.14467. [12] Gardner, W., States, D., & Bagley, N. (n.d.). The Coronavirus and the Risks to the Elderly in Long-term care. Journal of aging & social policy. https://pubmed.ncbi.nlm.nih.gov/32245346/. [13] Campbell, A. D. (2020). Practical Implications of Physical Distancing, Social Isolation, and Reduced Physicality for Older Adults in Response to COVID-19. Journal of Gerontological Social Work, 63(6-7), 668–670. https://doi.org/10.1080/01634372.2020.1772933. [14] Radwan, E., Radwan, A., & Radwan, W. (2020). Challenges Facing Older Adults during the COVID-19 Outbreak. European Journal of Environment and Public Health, 5(1), em0059. https://doi.org/10.29333/ejeph/8457. [15] Plagg, B., Engl, A., Piccoliori, G., & Eisendle, K. (2020). Prolonged social isolation of the elderly during COVID-19: Between benefit and damage. Archives of Gerontology and Geriatrics, 89, 104086. https://doi.org/10.1016/j.archger.2020.104086 . [16] Chu, C. H., Donato‐Woodger, S., & Dainton, C. J. (2020). Competing crises: COVID‐19 countermeasures and social isolation among older adults in long‐term care. Journal of Advanced Nursing, 76(10), 2456–2459. https://doi.org/10.1111/jan.14467. [17] Jacobson v. Massachusetts, 197 U.S. 11 (1905). [18] Jacobson. [19] Jacobson. [20] Jacobson. [21] Jacobson. [22] Jacobson. [23] Jacobson. [24] Jew Ho v. Williamson, 103 F.10 (C.C.N.D. Cal., 1900). [25] Jew Ho v. Williamson . [26] Jew Ho v. Williamson. [27] Viens, A. M. (2008). Public Health, Ethical Behavior and Reciprocity. The American Journal of Bioethics, 8(5), 1–3. https://doi.org/10.1080/15265160802180059. [28] Upshur, R. (2003, November 1). The Ethics of Quarantine. Retrieved from https://journalofethics.ama-assn.org/article/ethics-quarantine/2003-11. [29] Kamweri, J. M. M. (2013). The Ethical Balance Between Individual and Population Health Interests To Effectively Manage Pandemics and Epidemics (dissertation). [30] Argued by Ken Wing Professor Emeritus, Seattle University School of Law. Kamweri, J. M. M. (2013). The Ethical Balance Between Individual and Population Health Interests To Effectively Manage Pandemics and Epidemics (dissertation). [31] Interests To Effectively Manage Pandemics and Epidemics (dissertation). [32] Chu, p. 2457. [33] D'cruz, p.7. [34] Savulescu, J., & Cameron, J. (2020). Why lockdown of the elderly is not ageist and why levelling down equality is wrong. Journal of Medical Ethics, 46(11), 717–721. https://doi.org/10.1136/medethics-2020-106336. [35] Hugh McLachlan, Professor Emeritus of Applied Philosophy, [36] Heinrichs, B. (2010). Single-Principle Versus Multi-Principles Approaches in Bioethics. Journal of Applied Philosophy, 27(1), 72-83. doi:10.1111/j.1468-5930.2009.00474.x. [37] Gedge, E. by impact ethics · in C. E. (2015, July 27). What Is Dignity and Does Bioethics Need to Talk About It? Impact Ethics. https://impactethics.ca/2015/07/27/what-is-dignity-and-does-bioethics-need-to-talk-about-it/, citing, The 2005 UNESCO Declaration of Bioethics and Human Rights https://en.unesco.org/themes/ethics-science-and-technology/bioethics-and-human-rights.