This essay maps their contribution and considers anglophone Welsh women writers' adaptations and innovations of form (particularly romance) as they try to find a way of representing industrial landscapes, communities and the daily realities of industrial labour. It identifies the genesis in women's writing of tropes that would become central to later industrial fiction, including depictions of industrial accident, injury, death and disability. And it explores the representation of social relations  and conflict on this tumultuous, dangerous new stage.From the beginning of the genre, women writers have made a major contribution to the development of industrial writing. Although prevented from gaining first-hand experience of the coalface, Welsh women writers were amongst the first to try to fictionalize those heavy industries—coal and metal in the south, and slate in the north—which dominated the lives of the majority of the late nineteenth-century Welsh population. Treatment of industrial matter is generally fragmentary in this early women's writing; industrial imagery and metaphor may be used in novels that are not primarily “about” industry at all. Yet from  Mary Barton (1848) and North and South (1855), and George Eliot's Felix Holt (1866). But the heavy industry that dominated in Wales—coal, iron, steel and quarrying—is notable for its absence in the early canonical novels by women (and men).Women, Writing and the Industrial Revolution, mining is mentioned just once, in passing relation to Felix Holt, and there is a similar dearth in relation to women writers in earlier studies by Martha Vicinus and Catherine Gallagher.Jane Rutherford; or, The Miners' Strike (1853–54) is set in the 1840s and highlights the reforms of the 1842 Coal Mines Act.Life in the Iron Mills (1861), by Rebecca Harding Davis, is another example of a fictional engagement with heavy industry, although its innovative dreamlike style did not set the pattern for later novels. Frances Hodgson Burnett included some colliery scenes in That Lass o’ Lowrie's (1878), which was written partly in Lancashire dialect. In Wales, women writers began to incorporate industrial topography and workers into their fiction from around 1880.Women writers have been central to the development of the industrial novel, as with Elizabeth Gaskell's working-class literature depicting “a working man’s consciousness, his consciousness as a working man”, which Raymond Williams made central to his narrowly gendered description of the “Welsh industrial novel”.The industrial fictions discussed here are certainly not Undoubtedly, the generic conventions of romance ultimately draw the narrative away from overt industrial issues, and some ideological elements of the novels may be unpalatable to a modern audience, although the writing itself is not without merit. But our central claim is that this body of fiction, in which middle-class female novelists begin to make sense of their industrial regions—and to map the continuities between rural and industrial Wales—warrants a consideration on its own terms. Rather than reading these novels as lacking (in working-class authenticity) or as an immature phase in the development of an appropriate form , we try to consider the recurring concerns across the fiction in a more nuanced way. Thus, we focus on the common motifs and generic conventions of those novels by women writers which take their settings, or incorporate scenes and imagery, from industrial life. These include strikes and class conflict, injury and disaster, disability and caring, as well as recurring tropes such as hymn-singing and Christian faith, and conflict between English and Welsh. Many of these are themes which are taken up in later proletarian novels with which we are more familiar.The Queen o' the May (1880–81) was published by the Religious Tract Society in their Girl’s Own Bookshelf imprint.A Maid of Cymru: A Patriotic Romance (1901) is set in Powys among the limestone quarries which supplied the ironworks to the south. Williams was active in the Young Wales and Pan-Celtic movements, and the novel reflects these concerns. Allen Raine  was the best known of all these writers in her own time. Late in life, she became a bestselling author. Her novels are set in her native west Wales, and she had little direct experience of industrial regions, but A Welsh Singer (1897) and, more importantly, A Welsh Witch: A Romance of Rough Places (1902) include scenes set in the industrial south. Irene Saunderson (dates unknown) was the only author who wrote an entire novel set in the coalfields: A Welsh Heroine: A Romance of Colliery Life (1910).A Welsh Heroine bears more than a passing resemblance to Joseph Keating's Son of Judith (1900), a romance by a miner turned journalist. A sixth novelist, mentioned here only briefly, is Mabel Holland Grave (1861–?), who published a utopian novel Fraternity: A Romance (1888), which is part set in the north Wales slate quarries. Echoing Dillwyn’s call for a rapprochement between the classes in The Rebecca Rioter (1880), Grave's imagined cross-class fraternity is to be nurtured by an explicitly Welsh literature and culture.Many of the novels are out of print and the authors little known, so a short introduction is appropriate here. The five principal writers discussed are almost all from the upper or middle classes. In terms of wealth and social status, Amy Dillwyn (1845–1935) was probably the most privileged. Her father was a prominent Liberal Member of Parliament who owned a zinc works and had other industrial interests in the Swansea area, and metal extraction appears in her fiction.A Welsh Heroine, the industrial experience, imagined from without, remains somewhat marginal in the novels discussed here, either textually  or spatially . Yet, taken as a whole, Welsh women's industrial fiction is a substantial and pioneering attempt to “novelise”With the exception of Saunderson's Fraternity: A Romance. Part of the novel is concerned with “violent” and “ignorant” quarry workers in north Wales.What we find in these novels is a commentary on industrial relations from a particular bourgeois perspective. Strikes are viewed with regret if not outright hostility, yet the lot of the workers is portrayed as hard and always dangerous. Class conflict is not always a matter of misguided workers against paternalistic owners, as scenes in which soldiers aim their weapons at an unarmed crowd, or a gang of poachers shoot at a landowner suggest, and there is considerable sympathy amongst some writers for the discontents of the workers. The keynote of these novels, however, is rapprochement and fraternity, often framed in a specifically Welsh national context. Mabel Holland Grave gives the most detailed expression in In his discussion of “The Strike Novel in the 1890s”, H. Gustav Klaus suggests that there was an “unwillingness of the major practitioners of the novel to engage with industrial conflict at all. Class collision was, if at all, located elsewhere”.Chloe Arguelle (1881), Amy Dillwyn depicts mass poaching raids in which local working men turn skilled night-time hunters, defying landowners, magistrates, the police and even the local Member of Parliament. The novel describes “thirty or forty men, with their faces blackened, spearing salmon by torchlight quite openly. No one attempted to interfere with them and most of the inhabitants of the place quietly watched [ … ] from the bridge”.Reflecting the overlay of industrial life on older rural class tensions, poaching is frequently represented as a prelude to or substitute for industrial conflict. While poaching may seem a petty offence and lacking in the kind of organized resistance associated with working-class protest, it is, in fact, closely linked in fiction and history with other, more organized, campaigns. In A Maid of Cymru. The (English) quarry manager Garry Thoyts catches two of his workers with nets, ferrets and a sackful of rabbits. Acting on behalf of his cousin, the landowner and quarry owner, he confronts them. They refuse to give up their “pay” for their night's work, and a violent fight and chase ensue in which all three are hurt.The simmering threat of violence between workers and their overlords is played out in another poaching scene  in [ … ] this strike of Glascwm quarrymen is no small and simple matter—a mere dispute and difference between officials and men, which ye can settle or refuse to settle as ye choose. It is an affair that will be far-reaching in its consequences, for it affects our Motherland herself. (182)Leaving aside the point that industrial action is likely to be considered more than “a mere dispute and difference” by those engaged in the material sacrifice and struggles it entails, the strike is central to the main theme of the novel: national survival. The strikers are treated to a lengthy speech by a local bard, in which the Welsh are constructed in racial and linguistic terms, and the men are reminded that they face the danger of “a colony of [ … ] strange men of Somerset settle[d] in your homes”, since it is the “boasted ambition” of the English agent[ … ] to depopulate the Three Valleys of the “true red blood” and people them with aliens. [ … ] Make him laugh on the other side of his face by refusing to fall into the trap he has laid for you [ … ] and going back to your work in the quarries to-morrow, like loyal sons of Cymru. For Cymru is little and poor and weak, and she cannot lose her strong true-blood sons [ … ] Ye have a heritage to guard, and as you be true men, see that ye guard it well. (183–84)For their part, the poachers, in this national twist to the strike, will be “proud to sacrifice themselves for the good of their country” (184), compensated by “y Foneddiges” (184)—the gentlewoman and Welsh patriot of the title. Interestingly, the threatened anglicization or colonization of this corner of Wales extends beyond the immediate area of Dyffryn Crawnant and includes the “Three Valleys” of “Rhymney, Dowlais, and Tredegar”, thus casting the “great industrial centres” (31) as actual or potential colonial outposts and, of course, recording the enormous demographic shifts underway in the region.The motives behind the strike are based on family loyalty and the workers' belligerence: the poachers have “numerous relatives working at Glascwm” and the men are “only too ready, on the slightest provocation, to break out into open insubordination” (177). Yet the willingness of the poachers' “fellow-workers” to “leave the quarry to a man” (177) is also a show of community solidarity—one which the unsavoury English agent who manages the wider estate hopes to exploit. Determined to rid the valley of as many of the “native” Welsh as possible, the agent plans to bring in blacklegs from England, not so much to break the strike as to displace the Welsh from their workplace and homes. As one orator puts it to the men, who have assembled on the martially named mountainside Carnedd y Milwyr (“Cairn of the Soldiers”):A Welsh Heroine is rather more firmly rooted in the economic concerns of the working-class community it depicts. The basis for the strike is a demand for “a five per cent. rise”, although we are given no further context against which to measure the claim.The six-month strike central to Saunderson's The Queen o’ the May, one of the early agitators who is conveniently killed, along with his sympathizers, in a mine accident. In A Maid of Cymru, the foreman tries to keep the peace and persuade the English manager to respect local practices, but his task is really to mediate in the interests of keeping the quarry functional. Instead, the role of leader is performed by dynamic women with imagination and energy. Morfydd Llewelyn and Tangwystyl Hughes in A Welsh Heroine and A Maid of Cymru are two very different women, separated by social status and motives. But these determined women use similar techniques to provide direction and leadership to crowds of colliers or quarrymen: the power of Welsh hymns.According to H. Gustav Klaus, during the 1890s an “idealised portrait of the working-class leader” became a feature of “the altered approach of middle-class novelists [ … ] to the theme of industrial conflict. Once a ruthless demagogue or imposter, he now appears as the embodiment of integrity and self-abnegation”.The great hymns and hymn tunes have an incomparable personal and communal power. [… T]hey [ … ] empowered voiceless individuals and bonded people, sucked in from all parts by the vector of industrialization, together into coherent, structured, and orderly communities. These weren't the work of the professional classes. Hymns and melodies were largely the product of shepherds, tinplate workers, blacksmiths, miners and shopkeepers.In A Maid of Cymru, Tangwystyl gathers the strikers on a mountainside, intent on rousing their nationalism above more petty grievances. After the oration given at her request by the Eisteddfodic bard, she sings “songs of the Great Past—and of the Future Hope—the hymns they had first heard as lullabies from mothers’ lips, and those more solemn strains that would be sung over them when their ears were sealed in the great silence” (185), until the men agree to return to work with a cry of “Cymru dros byth!” (185),A Welsh Heroine, the personal and communal strength to be drawn from hymns is dramatized when Morfydd saves the panic-stricken crowd in “a gesture of inspired leadership” by singing “Mamgu’s favourite hymn” and walking “slowly forward to meet the terrible, levelled carbines” (164). The crowd joins in, “obedient as little children”, until “the hymn broke out with all the fervor of the Celtic ‘Hwyl’” (164) and the crowd marches away, past the armed soldiers—indeed, the soldiers mistake the Welsh hymn for a military “march” (173). For all its melodrama, this scene and the wider religious dimensions of the plotIf this seems a stereotype too far, we need to recall the social milieu from which these novels emerge. In his book on Nonconformist literature, M. Wynn Thomas describes the “visceral splendour”A Welsh Witch, miners trapped underground use hymns to sustain them as they face starvation and madness: “as his trembling voice grew stronger [ … ] some inward calm awoke within him, some strong faith, some hope revived, and with clear and sonorous voice, he sang”.The Queen o' the May. Much of the plot revolves around the passion for music shared by working folk and gentry alike. In this spirit, the mine manager goes down into the pit to try and counter the growing unrest amongst the miners: “I told them that the master was going to give them musical instruments and a trained instructor in the mines”. He is rebuffed: “’Tis more money, not more music we want”, protest some of the men, who refuse to listen to his offer. Almost at once there is an explosion, which the manager and those interested in the musical instruments survive, while the malcontents who have moved to a different part of the mine are all killed. If the moral message was not plain enough, the heroine asks: “Then it was those who were true to their duty that were saved?”The historian Philip Jenkins reinforces the importance in Wales “of the hymn as [an] expression of communal solidarity”, arguing that “the love of choral music” engendered by evangelical Nonconformity would become “a vital distinguishing feature of Welsh life, and by no means only for nonconformists”.Thus far, the focus has been on the ways in which industrial scenes and settings have been used in conjunction with other narratives—the nationalism of Mallt Williams or depictions of religious faith or (romanticized) female agency—as well as the way wider class conflicts merge with industrial disputes. In the second half of the essay, we turn to look at themes and tropes in women's pre-war industrial fiction which would eventually reappear in men’s working-class writing of the 1920s and 1930s.The Queen o' the May, which features a powerfully related colliery explosion told from the perspective of the frantic families of the victims and rescuers. The tense scene above ground would be repeated by Allen Raine and Irene Saunderson—the transfixed watchers by turns terrified and excited, the waiting punctuated by the movement of the pit cage, disgorging stretchers or taking in heroic rescuers.Industrial accidents and mining disasters are stock features of coalfields literature, included from the outset in women's writing. Female perspectives are privileged in Anne Beale's A Welsh Witch. Three men and a newly employed 12-year-old boy are trapped for several days after a roof fall caused by an explosion. They survive the afterdamp, but face starvation and madness. Stephen Knight suggests that Raine was “drawing on Joseph Keating’s 1900 novel Son of Judith”, but there is little to connect the two in style or plot.The action goes underground in Raine's The Queen o' the May, the heroine proves the value of her domestic skills, bearing restorative tea to exhausted miners, nursing the sick and injured, and offering emotional support and news to those unable to get to the pit. In A Welsh Heroine, when the men have done all they can, Morfydd goes underground to rescue the manager herself.If Raine focuses on a realistic account of men trapped below ground, the explosions in Anne Beale and Irene Saunderson provide an opportunity for female protagonists to demonstrate courage and strength. In The Queen o' the May, which conforms to David Mitchell and Sharon Snyder's description of Victorian “instructional tales” which “evidence a penchant for discussing disability in terms of individual responsibility and the need for charity [in this case filial duty] towards the infirm”.A Welsh Heroine, performs a similar role in caring for her frail Mamgu (“grandmother”), although she also earns money by taking in washing to help provide the nourishing food her aged relative needs.Although the drama of the fatal underground disaster remains a vivid literary reminder of the human costs of coal, more recent scholarship has focused on the fate of the maimed survivors of accidents and on the representation of disability in coalfields literature.Son of Judith is to win the right to increase the weekly medical insurance money taken from the miners' pay. Coalfields were important sites for the development of medical services to deal with both emergencies and the longer-term health needs of disabled miners. Irene Saunderson, no doubt informed by her husband's profession, mentions medical details with some frequency in A Welsh Heroine, including “our new ambulance service” (38) and the use of “beef-tea tabloids” (310) to sustain overstrained colliers during a rescue below ground. Even the ongoing debate about pneumoconiosis and the health of colliers' lungs seems to lie behind a detailed description of “the blood coursing” in Morfydd's “veins”, made “vigorous and buoyant” due to the mountain breezes “carrying the oxygen so necessary for the manufacture of good arterial blood” (94). Allen Raine tries to make a similar observation, erroneously claiming that, “fortunately for the colliers” who are covered from head to toe in coal dust, “it [coal dust] is not unwholesome, or their lives would be seriously endangered by the clogging of their skin”.While women remained the primary caregivers in late nineteenth- and early twentieth-century industrial centres, medical intervention and organized welfare systems were increasingly important—the strike in Joseph Keating's A Welsh Heroine, two of Saunderson's central characters are “disabled”. One is a sympathetically portrayed itinerant grocer with a wooden leg, the other a malevolent figure whose body represents his character. Named for his deformity, “Jack-y-bandy” (bandy-legged Jack) has “crooked legs, cumbered [ … ] with very large, flat feet” (20) that impede his movement, “a cadaverous face” (20) and “a very large head” (11), which lend him an “ungainly form” (13). Jack-y-bandy is an example of the long-standing connection between “sin and physical aberration”.In addition to the incidental medical discourse in dichotomy between normal and pathological”.hero’s body lies, broken and torn” . Arguably, the narrative remedies Jack-y-bandy's physical defects by omission in tandem with his spiritual restoration, but it also allows for a disabled body to be a hero's body.The “medicalization” of disability which occurred in the nineteenth and twentieth centuries, where impairments were increasingly viewed as “conditions” to be remedied or “normalized”, rested on a “Saunderson's treatment of the more attractive Jeremiah Jinkins is more subtle. Jinkins has a quasi-paternal role in this novel and, as such, is a double for the unpleasant Jack-y-bandy who, it turns out, is Morfydd's natural father. Jinkins finds laundry work for Morfydd during the strike and gives her the occasional gift of money or food, despite his status as a renowned miser. He is not defined by his disability—unlike Jack-y-bandy, who is named for his crooked legs—and neither his amputation nor his prosthesis symbolizes his character or soul, although his leg does render him a slightly comic figure, from the tap-tapping of his walk to his “affectionate” (101) regard and “customary study of his leg” (103), which are linked to his humorous portrayal as a “philosopher” (76).The portion that was snapped off from the wooden leg, reposed that night, wrapped up in an old shawl within the arms of a little child who had found it lying a yard or two away from the accident.“Bye-bye, dollie,” crooned the child, as she hugged her treasure-trove, and closed her eyes for the night. (80)Disability critics Mitchell and Snyder have argued that disability requires (and engenders) a narrative.A Burglary, or Unconscious Influence (1883). The burglary of the title involves a wealthy heiress being tied to her bed by a man disguised as a “poacher”, who then makes off with her jewels. He is, in fact, a gentleman thief, but his working-class disguise—and, in particular, the fact that he is missing a finger—successfully deflects attention onto a local collier and “notorious” poacher. In the eyes of the squire and local magistrate, a poacher is “capable of any iniquity”, and he believes that he has found his man.The ubiquity of industrial accidents and casual “minor” injuries is also utilized as a plot device in Amy Dillwyn's fiction. Disfigurement and disability in an industrial landscape are important elements of the detective plot of Jill and Jack, 1887); being thrown down an abandoned mine and left to perish ; dying from a blow to the head inflicted by refuse falling from a slag heap ; or being crushed and burned to death by a white-hot steel ingot (in the same novel). This last is a rare instance of a literary description of this kind of industrial accident, and Dillwyn offers a detailed and gruesomely realistic account of the event. The upper-class villain, disguised as a workman, gets into the path of men moving an ingot at speed to the “great hammer which was to beat it into shape”. They try to stop, but the ingot shoots off the trolley:There was a sound of a heavy body hurtling through the air, a shriek of sudden pain and terror, a crash, and then Reginald lay writhing and screaming on the ground, with his legs crushed beneath the weight of more than a ton of steel at nearly white heat. Then ensued a ghastly scene, whose recollection haunted those who witnessed it for many a long day afterwards.The first necessity was to procure long iron bars as levers, wherewith people could prize up the superincumbent mass of burning metal from off him, without approaching nearer to its fiery heat than flesh and blood could endure. […]  [W]hilst they were being hunted for and dragged to the spot, the sufferer had to lie in agony, with crushed limbs, and exposed defenceless to the heat that scorched and blistered him cruelly, and yet did not destroy consciousness.The scene goes on at some length, detailing the man's protracted agonies. Although Dillwyn, like Keating in Son of Judith, relies on a story which focuses on the “quality” rather than the ordinary workers, who were the most likely to be injured in the steel or coal industries, pioneering scenes such as this constitute an important and early fictional encounter with the dangers of heavy industry.The industrial landscape in which Dillwyn's characters reside is a potential danger in more than one novel. Several characters meet their end in industrial workings: by falling down a disused quarry (Welsh character of all the texts, which seem indebted to the contemporary Young Wales movement. In writing about colliery life, these writers foregrounded disability and care work alongside the more sensational disasters, industrial action and community cohesion which we tend to associate with later industrial literature. Taken as a whole, then, these early fictional representations of heavy industry in Wales constitute an important body of work that expands what we understand as industrial fiction.The middle- and upper-class women writers discussed here adopted romance as a flexible means to explore the industrial themes, scenes and settings which were transforming Wales—economically, linguistically, ethnically and politically—in the late nineteenth and early twentieth centuries. Irene Saunderson, who was the most immersed in the “colliery life” she wrote about, went furthest in trying to represent the bilingual, Nonconformist working-class world she inhabited with her husband, a doctor in the coalfields. The romantic alliance between an upper-class English officer and a working-class Welsh girl may seem absurd, detracting from both the astute ethnographic detail of her writing and her feisty working-class heroine. But melodrama also allowed Saunderson to represent the heightened class conflict that would, indeed, explode in a lethal confrontation between army and workers shortly after her novel was published. Other women writers were more concerned with a generalized class conflict, seeing the struggle in the mines as connected to wider inequities shared by rural workers, connecting scenes of industrial unrest with riots and poaching in the border zones where industry and rural life merged. Still others found a framework for transposing nationalist resistance onto working-class solidarity; indeed, what is perhaps most striking is the markedly and self-consciously


This paper introduces a special issue on ‘Histories of asylums, insanity and psychiatry in Scotland’, situating the papers that follow in an outline historiography of work in this field. Using Allan Beveridge’s claims in 1993 about the relative lack of research on the history of psychiatry in Scotland, the paper reviews a range of contributions that have emerged since then, loosely distinguishing between ‘overviews’ – work addressing longer-term trends and broader periods and systems – and more detailed studies of particular ‘individuals and institutions’. There remains much still to do, but the present special issue signals what is currently being achieved, not least by a new generation of scholars in and on Scotland. In spite of the wide interest currently shown in the history of psychiatry, little attention has been directed towards events in Scotland. … The lack of detailed research is somewhat surprising, when one considers that the Scottish contribution to the development of psychiatry has been substantial. : 4531 At least 30 full papers on Scottish themes have since been published in History of Psychiatry; a few book length treatments have appeared on periods , but the survey on Britain .To underline the importance of what Beveridge called ‘the Scottish contribution’ and also to profile some cutting-edge research that is currently being undertaken on Scottish themes, notably by a new generation of early career scholars, the idea emerged for a special issue of The Evolution of Psychiatry in Scotland, a book which perhaps more accurately could have been titled, ‘The Doctor Remembers’, based, as it was, on personal anecdote and reminiscence. .Madness and Society in Eighteenth-Century Scotland  which arose in several Scottish urban centres from the eighteenth century, followed by the ‘district asylums’  from the 1860s onwards. Parallel outline accounts of the royals and the districts surface in histories of Scottish philanthropy and social welfare : 271–84.England used to be seen as the norm for the development of institutional care; in fact, it followed only one of several pathways and Wales, Ireland and Scotland were different. … Scotland’s ‘mixed economy of welfare’ had more domestic care and a prominent voluntary sector; like Wales, it had few private asylums.The impression might hence be of a nineteenth-century will among prominent Scottish lay and medical authorities substantially to institutionalize the mentally unwell along the lines of what occurred south of the border, but non-institutional worldview about how best to deal with non-able (-bodied or -minded) paupers.Indeed, it is sometimes emphasized that Scotland significantly mitigated the resort to institutionalization by investing in a practice of ‘boarding-out’ lunatics, consigning them to the ‘domestic care’ of appointed guardians, individually or sometimes in twos or threes, particularly in the remoter localities . It is k3 Leaping forward chronologically, it is evident that a deep concern for liberty, informed by an abiding concern for justice, energized the agitations of the Scottish Union of Mental Patients (SUMP) in the 1970s, arising from Hartwood Hospital (the old Lanark District Asylum), as explored by Mark Gallagher (this issue). Paradoxically perhaps, Vicky Long , before progress might be made towards updating the ‘overview’ given by 4 Studies also exist touching on specialist Scottish institutions with psychiatric relevance, such as Craiglockhart War Hospital  has been persuasively placed in its urban-industrial context as less a humanitarian edifice than a response to ‘the economic and social concerns of the early-nineteenth century and the need to emulate the activities of other Scottish towns’ . AberdeeHospital  and JordHospital , while JHospital : ch. 7 dEnglish psychiatry, 1700–1980, moving lightly over contributions from, among others, George Cheyne (1671–1743), William Cullen (1710–1790), W.A.F. Browne (1806–1885), Alexander Morison (1799–1866), David Skae (1814–1872), Thomas Clouston (1840–1915), D.K. Henderson (1884–1965) and R.D. Laing (1927–1989). Some were ‘Scots decamping to England’ (The scholarship on people in Scottish psychiatric history has also blossomed. Psychiatrists past and present were name-dropped throughout England’ : 408, buEngland’ , Browne England’ , CloustoEngland’  and LaycEngland’ ; and to England’ , 1997b. England’ , which eEngland’ , 2012. MEngland’  he consiPhilosophy of Insanity, authored by James Frame, a patient at GRA in 1843, and again in 1856. The people in the eye of the psychiatric storm are the patients, of course, and various attempts have been made to access the circumstances and experiences of individuals admitted to Scottish mental institutions.


Beijing residents wearing face masks to protect themselves against extreme air pollution.As a result, Hoffmann says, burdening individuals with the responsibility to reduce their own environmental exposures can create or worsen environmental injustice, in which harmful exposures are inequitably distributed across a population.Moreover, Hoffmann fears that the tacit acceptance by a population of individualized efforts may limit their government’s incentive to protect all citizens through centralized actions. “This is not the way we want to go—to put the responsibility for breathing clean air on the individual instead of on the state,” she says. Instead, she argues, the state or central government can be much more effective at providing clean air and water to rich and poor residents alike through the passage and enforcement of adequate laws.The ethical line between centralized and distributed  solutions is a fine one, suggests Nino Künzli, deputy director of the Swiss Tropical and Public Health Institute and dean of the Swiss School of Public Health. “We have to acknowledge that there are individual rights and governmental duties,” he says. “The success of the latter may take years to fully materialize. In the meantime, individuals have the right to know how to protect themselves.”This right, however, does not guarantee awareness of the risk in the first place, the financial means to respond to it, or accurate knowledge of what protective measures to take.,The notoriously bad air in many Chinese cities is slowly improving overall, but long-term exposures are still many times higher than World Health Organization recommendations.Media reports often include photos of individuals who have turned to breathing masks—flimsy, mostly useless surgical masks as well as tighter-fitting particulate respirators—to protect themselves from the dangerous air. For many Western viewers, these images may be a symbol of the country’s failure to keep air pollution in check during its recent industrialization. For others, the masks may be an accepted part of modern life in rapidly developing nations like China and India: a small price to pay for lifting millions out of poverty. After all, countries in the developed world also experienced extreme pollution as they industrialized during the eighteenth and nineteenth centuries.The better masks can have benefits, even for healthy individuals.3, which is three times the WHO daily standard , which serve about 38 million people, or 12% of the U.S. population.Arsenic, for example, is a carcinogen that can be prohibitively expensive to remove centrally in small systems lacking economies of scale, says John Pujol, CEO of water-testing firm SimpleWater, Inc., which holds a license for a proprietary arsenic remediation technology it hopes to commercialize in the United States. As a result, arsenic often goes untreated in such systems, even at levels known to be unsafe and that significantly exceed the federal limit of 10 ppb.That’s what has happened in nearly 100 small systems serving 55,000 people in California alone, according to a recent report by the Environmental Integrity Project, an environmental watchdog group.Many Americans simply don’t trust centralized treatment systems of any size to deliver safe water to their homes, suggests Joseph Cotruvo, a public health consultant and former director of the EPA Drinking Water Standards Division. A 2015 national telephone survey by the Water Quality Association, which represents the water treatment industry, found that 59% of respondents were highly concerned about contaminants in their drinking water, 43% used a water filter, and 70% maintained that the municipality, not the individual, still bore ultimate responsibility for drinking water safety.“If you look at public perception and concerns, a very high percentage of people have negative perceptions of their drinking water,” says Cotruvo. “So they’re voting with their pocket books, buying bottled water or filters.” Yet Cotruvo, whose tenure at the EPA began in the agency’s earliest days, also believes that in some cases this perception is misdirected: “Municipal water in the U.S. is actually safer than ever, especially since the implementation of the Safe Drinking Water Act,” he says.,,That said, the recent crisis in Flint, Michigan, did not help public perception of centralized water treatment. It also revealed the challenges of distributed treatment on a large scale. In late 2015, a full year and a half after switching its water source from the Detroit Water and Sewerage Department to the corrosive Flint River and setting off perhaps the highest-profile drinking water crisis this country has ever seen, the city began offering free filters to residents concerned about the safety of their water. This improved people’s access to safe water but only among those who were already aware of and able to act on the problem.Two months later, Flint mayor Karen Weaver expanded the program’s reach by declaring an official emergency and advising residents to drink only bottled water or filtered tap water.,,In November 2016 a federal court asserted as much by ordering the home delivery of bottled water to any Flint resident lacking a verified water filter. City and state officials twice fought the order—saying it would cost Michigan at least $10.45 million a month—but lost.Legionella bacteria.Aside from lead, other agents and factors raise new questions about what constitutes drinking water safety. These include emerging chemicals of concern that cannot always be removed, such as pharmaceuticalsAt the heart of these issues is a philosophical and practical question about the role of centralized versus distributed solutions within public water systems. The centralized water treatment plants and distribution systems built in American cities and suburbs over the last 100 years were designed under the premise that in-home treatment shouldn’t be necessary, says David Sedlak, a professor of environmental engineering at the University of California, Berkeley. That view persists, he says, even as weaknesses of the centralized model have emerged in recent years.If the most ethical solutions to air pollution are always centralized, with drinking water it’s not so black and white. Programs like Flint’s that use existing public funds to subsidize filters and bottled water during an emergency appear to be on solid ground ethically—provided, of course, all residents have equal access. A public water system that is out of compliance with federal water standards and delivering potentially unsafe water, by contrast, places the burden squarely on individuals to be aware of and then attempt to mitigate the problem themselves.Still, most experts don’t recommend that large or even medium-size water systems seek to systematize point-of-use treatment—that is, gain EPA approval—because it can become a logistical  nightmare. In their appeal of the federal order to deliver bottled water to any of Flint’s 100,000 residents without an approved filter, state officials said such a plan would require a “Herculean effort” and increase the scope of Michigan’s emergency response “to an unnecessary and insurmountable degree.”Instead, experts including Cotruvo believe reverse-osmosis units and other under-sink or faucet-mounted filters represent an attractive option for small, often cash-strapped systems across the country hoping to provide safe water and stay in compliance with federal and state regulations.Yet a bevy of regulatory and economic hurdles can stand in the way of this strategy. According to federal policy, the water system operator or utility bears all responsibility for purchasing, installing, and maintaining the devices, including inspecting every unit annually.“The problem is that it requires a pretty sophisticated maintenance and regulatory apparatus that doesn’t currently exist,” says Pujol. There is also a problem with perception, notes Sedlak. He explains, “There is this belief among people who are involved in centralized water systems that moving toward point-of-use is regressing and is basically admitting that we can’t deliver safe water in a centralized system.”If point-of-use treatment were to be more readily accepted at the federal and state levels, Cotruvo believes, many people nationwide could quickly gain access to safer water. Instead, only a tiny number of water systems nationwide—fewer than 100 out of 150,000, Cotruvo estimates—have sought and gained approval to use distributed solutions to maintain safe water system-wide. Many others simply fall out of compliance with federal law.The EPA reports that in 2013, the most recent year for which it has tabulated data, 27% of all public water systems—serving roughly a quarter of the U.S. population—had at least one “significant” violation of the Safe Drinking Water Act, a category that includes both technical and health-based violations.Since out-of-compliance systems are more likely to be small, and small systems are more likely to serve rural and low-income communities, the current system puts citizens who are already underserved at a potential disadvantage. Additionally, contaminants such as naturally occurring arsenic and agricultural chemicals are more likely to be present in lower-income regions like the rural Midwest and California’s Central Valley.Peter Gleick, president emeritus and chief scientist of the nonprofit Pacific Institute, says he believes recent developments have led U.S. public water systems to a fork in the road. Down one path is the potential to rebuild water systems to a higher standard, including through less-centralized approaches.Down the other is a future he describes as a “downward spiral in the quality and cost of our water systems,” where the rich install point-of-use systems and the poor are left relying on bottled water or drinking whatever comes out of the tap. Already, Gleick says, poor infrastructure, rural water contamination, and poverty threaten basic water services for millions of Americans. “Inequitable access to safe and affordable drinking water is a large and growing problem,” he says, “and should be an embarrassment for a country like the United States.”


To address the relevant ethical issues, we promote a critical experimentally based ethical approach to social robotics, “synthetic ethics,” which aims at allowing humans to use social robots for two main goals: self-knowledge and moral growth.Social robotics entertains a particular relationship with anthropomorphism, which it neither sees as a cognitive error, nor as a sign of immaturity. Rather it considers that this common human tendency, which is hypothesized to have evolved because it favored cooperation among early humans, can be used today to facilitate social interactions between humans and a new type of cooperative and interactive agents – social robots. This approach leads social robotics to focus research on the engineering of robots that activate anthropomorphic projections in users. The objective is to give robots “social presence” and “social behaviors” that are sufficiently credible for human users to engage in comfortable and potentially long-lasting relations with these machines. This choice of ‘applied anthropomorphism’ as a research methodology exposes the artifacts produced by social robotics to ethical condemnation: social robots are judged to be a “cheating” technology, as they generate in users the illusion of reciprocal social and affective relations. This article takes position in this debate, not only developing a series of arguments relevant to philosophy of mind, cognitive sciences, and robotic AI, but also asking what social robotics can teach us about anthropomorphism. On this basis, we propose a theoretical perspective that characterizes anthropomorphism as a basic mechanism of interaction, and rebuts the ethical reflections that  R.U.R. ,” from which science and engineering inherited the term, the human-like artifacts called “robots” are artificial social agents that function as secretary, postman or factory workers  appearance and autonomous movement or behavior . The basascribes human traits to non-human entities, while, in the case of social robots, infers these traits from the behavior of the non-human entity. Note that this distinction partially overlaps the difference between the two factors analyzed above: on the one hand, the static human-like (anthropomorphizing) appearance of the robot seems to correspond to the simple ascription of human traits, while, on the other, the dynamic realism of autonomous movement appears as the basis of the inference from behavior.Research in SR tends to emphasize the plural articulation of anthropomorphism . InteresThis distinction between different forms of anthropomorphism is also important to understand the ambiguous relationship that SR entertains with anthropomorphism. Inasmuch as it is inseparable from a comparative evaluation of the two forms, this distinction reveals a partial re-alignment with the negative attitude that remains dominant in science . ProjectThe project of endowing robots with social traits, or making them able of social “performances,” does not require robots to understand the performed task, nor to have the social “competences” and “properties” that underlie this understanding . If this1, whose realistic animal-like appearance encourages anthropomorphic projections, in spite of its limited social AI; (ii) robots like Jibo2, whose appearance is not conducive to anthropomorphism, but which nonetheless gives rise to such projections because of its sophisticated social performances; and (iii) robots like Affetto3, whose anthropomorphic appearance is matched by high level social AI. It is important to note that all social robots, independently of where they are located on this spectrum, tend to reach the threshold at which, in the eye of the user, objects become subjects. This is indicated, or at least strongly suggested, by research on human users’ representations of social robots  robots like Parol robots . Empiricl robots . Accordil robots . Human uThe ambiguous status of social robots became the origin for a new scientific endeavor, whose relevance grows as the comparison between humans and social robots yields ever more ambivalent results. As the frontier between humans and robots is progressively blurred, the question of what constitutes human identity, or particularity, is raised anew. On this basis, anthropomorphizing robots make possible a novel science of human beings , in whicDespite the unquestionable scientific interest of this new research direction, related technological applications in SR raises questions. Current literature emphasizes how highly human-like robots can be perceived as menacing by users, especially when they appear able to perform better than humans  and disp4  users, from cognitive and psychological damages to manipulability and reduced quality of lifereal social relations, with genuine and reciprocal affect and emotions, while they simply cannot. Thus, Turkle sees in social robots a further step in the development of our “culture of simulation,” which threatens to turn people away from “real” social relationships – that is, from relationships with other humans – and reduce their social life to an illusion – to the feeling of being together with someone, when in fact one is alone. She concludes her radical criticism of all anthropomorphizing computational technologies by claiming that they “should not be allowed into the realm of human relationships”  with a pre-established set of ethical rules.The difference between a ‘dichotomous’ and a ‘synthetic’ approach to the ethics of SR should not be underestimated. The theoretical and epistemological choices we make in order to think, create, understand and regulate social robots will dramatically impact human–robot co-evolution – a mixed social ecology where ethical life may flourish.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. The authors elaborated plan and contents of the article together. Each author is responsible for the final form of different parts of the article: Luisa Damiano for Introduction, Section 1  and Subsection 2 (Synthetic Ethics) of Section 3 (From ‘Dichotomous Thinking’ to ‘Synthetic Ethics’); Paul Dumouchel for Abstract, Section 2  and Subsection 1 (From Condemnation to Impotence) of Section 3 (From ‘Dichotomous Thinking’ to ‘Synthetic Ethics’).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Behav Ther. 17(5):607–19, Transl Behav Med. 6(4):546–57, In 1986, Lichtenstein et al. ( Social Support in Smoking Cessation: In Search of Effective Interventions, and its main conclusion was that “attempts to both increase social support and to enhance treatment effectiveness have not been successful.” Thirty years later, the paper by Cutrona et al. [In 1986, Lichtenstein et al. [a et al.  draws a In the years since the study of Lichtenstein et al. , dozens With the widespread proliferation of social media and online social networks, there has been renewed interest in evaluating the role of social support in behavior change through online interventions. Conceptually, online social networks have the potential to overcome many of the challenges of social support interventions conducted in face-to-face settings . The relDecide2Quit.org smoking cessation website were offered the opportunity to visit and join the online community that is part of the BecomeAnEX.org smoking cessation website. The authors found that only one in four Decide2Quit users clicked through to BecomeAnEX, only 7.5% registered, and the level of engagement and exposure on BecomeAnEX was too low to create a clinically meaningful impact on abstinence. Considering these findings alongside other studies of online social networks—and the wealth of research that has been done in “offline” settings—we have identified three “lessons learned” that are relevant for the study of online social networks. Given that research on online networks is very much still in its infancy, investigators would be wise to benefit from existing knowledge on social support, social networks, and community building.Online Community Manifesto, Millington [“Community is the noun, online is the fancy dressing.” In his llington  calls foThe study by Cutrona et al.  attempteOn its face, the approach that Cutrona et al.  took in 2.“Nature knows best.” While not a scientific construct per se, the importance of interpersonal “chemistry” cannot be overlooked in this line of research. We choose who to befriend among our neighbors, our coworkers, and the people we encounter through shared experiences like parenting, sports, book clubs, and quilting. Whether or not someone seeks out interpersonal support or social contact as they make lifestyle changes is influenced by a whole host of factors, many of which may not be malleable or amenable to intervention. These factors may include past experiences, personality characteristics, complex psychological constructs like outcome expectations and trust, social competence or interactional skills, the nature of the health behavior itself, and potential stigma that may surround it, to name just a few. There is even emerging evidence of an association between the structural and functional properties of the human brain and the size and complexity of social networks . For somThe authors note that the need to register on Decide2Quit and again on BecomeAnEX may have acted as a deterrent to full participation in the online community. We agree that this was a limitation of the study, and offer an additional perspective. Successful online communities are dynamic, living entities that facilitate participation because users find value in others’ contributions, feel a sense of connection and shared experience with other members, and feel safe in participating. This is true for any community, online or offline. For online communities, in particular, the technology needs to sit quietly in the background, seamlessly facilitating these social processes. The low click-through rates and even lower engagement rates reported in Cutrona et al. [3.“Well-designed observational methods offer an alternative to doing nothing.” As noted by Black , observaDecades of research on social support interventions may simply be telling us that social support is not for everyone, and among those for whom it is important, the social relationships that form naturally yield the greatest benefit. Social interactions should not be presumed synonymous with social relationships nor should they be expected to have the same impact on perceived support, received support, and health behavior change. Furthermore, interactions with “grafted” helpers may be fundamentally different than interactions with “indigenous” helpers . These aAs mentioned by Cutrona et al. , analysiFurther, it appears that Cutrona et al.  did not Finally, outcome modeling should correctly treat the propensity weights as probability weights and not precision weights . OtherwMechanisms Linking Social Ties and Support to Physical and Mental Health [Research also needs to focus on the mechanisms through which greater engagement in online social networks is theorized to impact behavior change rather than simply the overall effect of engagement itself. A 2011 manuscript by Thoits titled l Health  is a musl Health . It is pl Health . The conl Health –31. The Recognizing that social interventions are not for everyone is not to suggest that they are for no one. Hundreds of thousands of current and former smokers connect each year in online communities offered through state quitlines , employe


Dateline 1981. NYU medical student Phil Rosenthal had recently done clinical work in Kenya and would soon go to India, both overseas rotations spurring his interest in tropical medicine and malaria.Leishmania researcher at Tufts. That its Division of Geographic Medicine existed at all was thanks to Ken Warren, a man who, four years earlier, had arrived at the Rockefeller Foundation with a bold, new vision.Claire Panosian was a newbie In 1981, Warren gave the 46th Charles Franklin Craig Lecture at the ASTMH meeting in Atlanta. In “The Bench and the Bush in Tropical Medicine,” he stated: “Whenever I am asked what my specialty is, my reply is tropical medicine; the one annual meeting I almost invariably attend is this one and the organization I care most about is the American Society of Tropical Medicine and Hygiene.”1—paints a rich portrait of the Rockefeller Foundation’s charismatic, free-wheeling Director of Health Sciences. And although his Rockefeller tenure lasted only 11 years, even today—more than two decades following his premature death—Warren’s influence lives on.But who was Warren, exactly? A new book by Conrad Keating of the Wellcome Unit for the History of Medicine at the University of Oxford—“Kenneth Warren and the Great Neglected Diseases of Mankind Programme--The transformation of geographical medicine in the U.S. and beyond”chutzpah is sometimes needed to reach for the stars. Consider the closing sentences of the 1981 Craig Lecture,2 which testify to Warren’s core belief that tropical medicine was ripe for a re-birth.“I would now like to close with thoughts presented by Joshua Lederberg, Nobel Laureate and President of Rockefeller University, at a recent meeting on the Present Status and Future of Parasitology. He described biomedical research on parasitic diseases as a new wave in the application of immunology, pharmacology and molecular biology to a new era of discovery of disease mechanisms, pharmaceutical agents and vaccines that would rival the great advances in microbiology of 40 years ago. Research in parasitology would thereby fulfill the public’s expectations which have languished so long in the Sargasso Seas of cancer and cholesterol. The opportunity is here, but to maximize it we must combine the knowledge and experience of the bush with the exceedingly powerful tools of the bench into new and more effective synthesis.”Author Keating deserves kudos. Not only has he produced a deeply-researched history which unwinds 40 years of global health policy interwoven with Warren’s jet-fueled life, he also reveals how a special mix of brains, energy, and In short, the Harvard undergrad who studied history and literature was just as enthralled by the promise of new vaccines and treatments for parasitic diseases. Warren’s own work in schistosomiasis--first at the NIH Laboratory for Parasitic Diseases, then at Case Western Reserve, St. Lucia, and other overseas sites—mirrored this hope. After leaving Cleveland, Warren was also uniquely positioned to attract fresh talent to the “new” tropical medicine. After creating the Rockefeller-funded “Great Neglected Diseases” (GND) network, for example, he also launched the yearly “Biology of Parasitism” course which continues to this day at the Marine Biological Laboratory in Woods Hole, Massachusetts.New England Journal of Medicine marked Warren’s brave foray into the high-stakes debate over how to advance global health writ large. Warren co-authored “Selective Primary Health Care—An Interim Strategy for Disease Control in Developing Countries” with Julia Walsh, a newly-minted infectious diseases specialist with an MSc in Community Health from the London School of Hygiene and Tropical Medicine.3 Like Phil Rosenthal a decade later, Walsh also worked in Kenya and India, ultimately concluding that many of the deaths she saw—whether from malaria, diarrhea, respiratory infection, or diseases which a vaccine might have foiled--were preventable. By the end of a year-long stay at an 120-bed hospital in Kenya, “the only sustainable piece of my husband’s and my work was a small nursing school,” Walsh recently shared.In 1979, a seminal paper in the 3 herald “burden-of-disease” metrics that would later transform into disability-adjusted-life-years (DALYs) in the historic 1993 World Bank report, “Investing in Health.”4Thus the seeds were sown for the Walsh-Warren collaboration weaving input from a Bellagio “Health, Population, and Development” conference. As Keating recounts, the ideas reflected a cost-conscious realism which flew in the face of WHO’s then-“Edenic” hope of providing primary health care for all of the world’s poor. In addition, although admittedly imperfect, the data for prevalence, mortality, and morbidity of the major infectious diseases of Africa, Asia, and Latin America found in Table 1 of the 1979 article“Ken was extraordinarily energetic and enthusiastic, talking about one idea and then sometimes another—and another—in short succession,” she e-mailed. “But he also stimulated others to come up with their own ideas and modify and improve his. He frequently talked too much and interrupted directors of agencies at meetings [held] in Bellagio or at the Task Force for Child Survival … this likely annoyed others and ensured his reputation as brash and an upstart…”Years later, Walsh can still evoke Warren’s iconoclastic passion. “He believed that modern science was not being applied to tropical infectious diseases and that change would occur only if basic science and clinical departments in medical schools were involved. He perfected the bush-to-bench and bench-to-bush paradigm at Case Western Reserve, then expanded it through the Rockefeller Foundation’s Great Neglected Diseases network. Evidence was coupled with experience, and explosive thinking with engagement. How did this influence the current era of global health? In every way we now engage in capacity strengthening and patient-centered research collaborations.”In another recent e-mail, Gerald Keusch, the former Chief of Geographic Medicine at Tufts who later served as Director of the Fogarty International Center at NIH credited Warren’s foresight. One of the special pleasures of reading Keating’s book is remembering other global health “greats” and mulling memories of scientists and peers whose lives Warren touched. The list is long and illustrious, including Past ASTMH Presidents Joe Cook, John David, Dick Guerrant, Scott Halstead, Peter Hotez, and Jim Kazura among others.Finally, Keating’s book combined with Warren’s example compel us to examine current global health challenges. In September 2017, Phil Rosenthal developed three questions which were posed to Julia Walsh and Jerry Keusch. Their responses follow.The Keating book raises a difficult question we continue to debate today. What’s the best way to balance investments in neglected diseases considering the “Big Three” infectious killers  plus many other pathogens, for example, new, virulent strains of influenza and other emerging viruses--diseases like polio nearing eradication—and diseases which are either common yet uncommonly severe or uncommon but fatal or disabling?Julia Walsh: As one on the outside of large philanthropic institutions, I believe that the investment priorities must be saving lives and [preventing] disability. This usually means assessing the landscape of investments by other institutions and governments and looking for opportunities where an organization can truly make a difference. For example, if your organization has strong experience in a specific topic, issue, or geographic area, build on that experience.In setting priorities, I would then consider the global burden of disease and what is cost-effective, either in program implementation or in research.  agencies, institutions, and foundations will make their own decisions.Finally, the book provides an excellent example of ‘donor fatigue.’ At the end of Ken’s term at the Rockefeller Foundation, the President and Board of Directors simply wanted to invest in something different. This shows how health investments are affected by many factors beyond the desire to save lives. At the same time, however, Ken’s commitment to long term funding was key to the GND’s success.Jerry Keusch: Ken was an unbridled optimist, but he was also a realist. Because he knew that not everything that could be done to improve health in developing countries could be done all at once, he balanced available resources to maximize the reduction of DALYs. He also ranked problems according to the current availability of strong, cost-effective tools. Finally, he wanted to assure that priorities were set by affected countries and not by international collaborators with pet projects and diseases, or by rich-country development assistance agencies.How do we balance investments in basic, translational, clinical, and implementation research? Ken Warren contributed by emphasizing the importance of translational research linking bench and clinical interventions. Today, implementation science research is all the rage, and carries the short-term allure of immediate, field-relevant results. But without basic research, we can’t fully benefit from scientific advances. What's the best way to think about this juggling act?Julia Walsh: The difficulty in setting research priorities was revealed by a National Academies model developed several years ago, updating a 1984 exercise in which I participated. An extensive model of factors affecting vaccine research priorities was developed; researchers could then numerically adjust factors, observing their effect on priority scores. The principal factors were deaths, disability, epidemic risk, economic impact of disease, cost of research, time frame for results, likelihood of successfully developing a new vaccine, ease of manufacture, the cost of the new vaccine, ease of incorporation into current vaccine program, predicted efficacy of the new vaccine, and an estimate of death and disability averted with accommodation for socioeconomic change. The model demonstrated just how many factors influence a future vaccine’s dividend at the same time the model’s complexity made it difficult to use. Modeling all diseases in this detailed way is frankly impossible.However, in setting research priorities, what is paramount is to first address the biggest problems producing death and disability and to find preventive measures and/or treatments ripe for cost-effective development.Jerry Keusch: There is no clean answer to the question of how best to set research priorities. The best I can come up with is simply to invest across the full spectrum of the research enterprise from basic discovery to translation to implementation. Simply applying what we know now is likely to ensure that, in 10 years’ time, we are 20 years behind and may even be championing approaches that do more harm than good. There is no good investment in application that does not contain the mechanism for learning, just as there is no good investment in discovery science that does not contain a long-term goal of application.Finally, there's the age-old vertical versus horizontal question. Some major funders favor vertical approaches  but not always. Warren also liked vertical investments, but the horizontal strategy still has many proponents, and, let’s face it: the great improvements in health indicators seen in recent decades could be mostly due to better living standards as opposed to interventions focused on single diseases. So, once again: how do we sort out investments?Julia Walsh: The evidence linking improved health and rapid gains in socioeconomic status is very strong. There is no doubt that better health results in greater family and community wealth. Therefore, first and foremost: save lives and decrease illness in the poorest areas which lack even the most basic services. If the world wants to eliminate extreme poverty, it should invest in programs that cost-effectively save lives.Vertical programs that are cost-effective, easy to implement, and save lives are the priority. These include expanding vaccine coverage, family planning, and malaria prevention and treatment. Vertical programs--especially those that involve medicines or vaccines—also strengthen health systems by training health workers and improving disease surveillance, health records, equipment, and systems of logistics and supply, among other areas. In short, the tension between ‘vertical’ and horizontal’ has been overstated.Jerry Keusch: I agree this is a false dichotomy. There is no simple endorsement for vertical or horizontal programs. In some instances, a vertical program is the best option. Polio eradication is a contemporary example. The existence of a polio eradication program with trained contact tracers not only brought the latest wave of polio in Nigeria under control, but because it was quickly reassigned to Ebola contact tracing when Ebola reached Lagos and Port Harcourt in 2014, it helped halt Ebola in Nigeria, thus saving the country and the world from a potential disaster far greater than Ebola’s earlier toll in its three epicenter countries.On the other hand, horizontal programs such as child survival have greatly enhanced the effectiveness of healthcare workers to address various causes of morbidity and mortality using the same infrastructure. This, in turn, saves lives and money which can be used to save more lives. First and foremost, Ken wanted information and innovation. I never saw him favoring vertical over horizontal interventions. He would have said: what is the problem, what potential solutions do we have, and what is the optimal approach to derive the greatest benefit in the shortest possible timeframe.


The 18th-century Scottish ‘common sense’ philosopher Thomas Reid argued that perception can be distinguished on several dimensions from other categories of experience, such as sensation, illusion, hallucination, mental images, and what he called ‘fancy.’ We extend his approach to eleven mental categories, and discuss how these distinctions, often ignored in the empirical literature, bear on current research. We also score each category on five properties (ones abstracted from Reid) to form a 5 × 11 matrix, and thus can generate statistical measures of their mutual dependencies, a procedure that may have general interest as illustrating what we can call ‘computational philosophy.’ Our task in this paper is to re-introduce to current researchers a logical basis for the distinction between perception and sensation due to the Scottish ‘Common Sense’ philosopher Thomas Reid (1710–1796), and to show how his approach helps us distinguish between other categories of perceptual experience. We say ‘re-introduce’ because recent developments in Neuroscience, admirable, even astonishing, as they are, have sometimes obscured such distinctions. We suggest that this phase in the history of science is temporary, and that insights are to be gained from the older terms, even though they reflect a refined ‘folk’ psychology  or what 1 and representation. Very briefly, he viewed ideas and experiences as mental activities rather than being private mental objects (as in Hume and Berkeley), and instead of deriving perception from sensation, he analyzed perception into conception and belief, claiming that perception was normally, but not always, accompanied by sensation. He argued for nativism and direct perception, as well as contributing to broader philosophical topics in ethics, aesthetics, free will, and the philosophy of mind , must be experienced, and must be believed to exist (‘fixation of belief’). For example, for ‘I see a dagger before me’ to mean ‘I perceive a dagger before me,’ then my eyes must be focused on the dagger, it must be present , I must experience it as a dagger, and I must believe it to be there . The Common Sense School advocated a straightforward approach at the expense of a deeper analysis of the logical conditions of knowledge in epistemology and ontology; thus, the various mental categories and their properties are asserted, perhaps dogmatically, rather than derived. Such an approach might not satisfy modern philosophers, and did not satisfy philosophers subsequent to Reid, but we think it suited to the current state of psychology, in which the fundamental status of the mind, and of consciousness, remains unsettled.According to perceive the UFO. If one walks downstairs while in the deeper stages of sleep, and thus one is not aware of the hallway and stairs (to judge from reports of somnambulists when abruptly woken), then one does not perceive them. Reid’s definitions invite us to not only to ask what perception actually is, but also what is it not. Are sensation and perception, for example, one and the same thing? Current researchers often run them together, in part because sensation, like perception, procures us with knowledge of the external world, or distinguish them only insofar as sensation provokes emotion. Indeed, once a needle inserted into our skin has triggered a sensation of pain, we are unlikely to forget it, and we will know in the future, whenever a needle approaches our skin again, that it will cause pain and may try to avoid it. Sensations, like perceptions, can inform the planning of adaptive behavior and allow us to cope with real-world situations. Yet sensations can arise at different levels of consciousness, during wakefulness, sleep or anesthesia, and they may be present in the absence of a real-world stimulus triggering them, as in the case of phantom limb sensations . In contrast, a recent, superficially attractive, quotation illustrates the difficulties which occur when Reid’s distinction is ignored:This is in contrast to the tree, which really does exist – not just as an idea, ua e.g.,  or treatua e.g., . Yet, sepercepts — the colors, shapes, and sizes (etc.) of the objects and surfaces that populate our visual experiences. Imagine looking at an apple in a supermarket, appreciating its redness  and anticipating the delicious juicy sensation it will cause in the mouth when you dig your teeth into it, that is perception in its deepest sense”  becomes the source of a sensation with direct and immediate consequences for behavior  and parahippocampal and fusiform gyri; and parietal differences can reflect belief status , suggesting that images and percepts share similar access to memory, interpretation, and action control . Howeverf status . These rTable 1, and are as follows: perception, sensation, illusion, hallucination, mental image, and ‘fancy,’ the latter term being Reid’s but expanded on by S.T. Coleridge. To these we have added several modern categories: affordance, body image, subliminal percept, ganzfeld, and eigengrau. The list may prove incomplete, but it incorporates insights from neurology, psychophysics, and ecological optics. In adding and simplifying categories, we lose some of the clarity of Reid’s presentation, and we risk the inclusion of dissonant elements, but we remain true to the ‘common sense’ goal of making philosophy useful to science, in particular to experimental psychology. Rather than claiming our categories are necessary or exhaustive, we take the weaker approach of “categorical descriptivism” ; we added a fifth, whether a proximal stimulus is needed, as this is not implied by the others. The properties are complete to the extent that they define all the ways experience and reality can inter-relate structurally – that is, without regard to specific content.Each category in Table 1 from the most to the least reality-oriented. The next section justifies our scores for each of the categories in turn.We scored each property using a ternary system, as +1 if it held true of a category, -1 if it did not, and 0 if it was irrelevant or ambiguous. Binarizing by assigning +1 to truth and -1 to falsity is standard, but using 0  is valid only on the assumption that degrees of uncertainty are unsystematic and average to zero. All scores have the same direction in terms of realism, from perception  to fancy , so the mean score indexes reality. Between perception and fancy lie the intermediate categories, which we now characterize in the order shown in 3, must be believed to exist, and in addition, there must be a proximal stimulation to a distal sense . Thus percepts are scored as +1 on every property in Table 1. We note that perceptions of absence, such as “I perceive no elephant in my room,’ are not included in this definition. Absence is redundant, in that the numerous possible objects whose presence is to be denied are implied by what I do see, given that objects are opaque. Here, we follow Reid: “The more obvious conclusions inferred by reason from our perceptions constitute what we call common understanding” , but not necessarily visual objects (scored 0), as affordances can also specify landscape, air, lakes or sea. In Gibson’s system, affordances are detected by picking out invariants in the optic array, such as the ‘nesting’ of visual angles. Since the information specifying the affordance must be actively attended to affect action  vs. neural processing and awareness (perception). Thus affordance and perception are not equivalent – and neither are equivalent to action.An ‘affordance’ is a feature of the physical environment that permits (‘affords’) a behavior, such as the ground being flat enough to permit running, as defined by t action , we scor4.A ‘sensation’ is a mental event requiring processing activity in a sense organ or at higher levels of brain integration, as in the case of phantom limb sensations. Sensation requires a sense organ to register a proximal stimulus (score +1), as when one senses light or sound, or one feels bodily pleasure. In normal seeing and hearing, proximal stimulation is nearly always caused by distal stimuli (score +1), although one can also see stars when one rubs one’s eyes. Following Reid, sensations do not require that their origins be interpreted; there is no necessity that an object exist, or nor that belief be fixed (scores 0), though they may be. Because sensation is so tied to the sensory nerves, it can be defined medically as the response in the brain to neural activity originating in the sense organ, but here, the phenomenal nature of the sensation, not the neural channel communicating it, is primary. A sensation is first and foremost an experience – it requires the activity of the sensory organ, but cannot be defined by it5.An illusion in psychology is a mistaken percept, one that one may know is wrong but cannot correct – being ‘cognitively impenetrable.’ Classic examples include the Mueller-Lyer, Poggendorf, and wagon-wheel illusions; modern illusions include a host of motion-generated illusory percepts. In all cases, one is aware of the object, but it is misinterpreted, so we score +1 for awareness and -1 for object. Indeed, illusions typically derive from incomplete stimulation, as pointed out by anorexia nervosa where people perceive themselves as unrealistically fat, or in schizophrenia where they may perceive parts of their body as distorted , but distal stimulation and real-world objects are absent (both score -1). An example is the man who ‘mistook his wife for a hat.’ Hallucinations do not have to, but may involve proximal stimuli (score 0), since such stimulation may also arise within the brain . There i6.A ‘subliminal percept’ requires both a proximal and distal stimuli stimulus (scores of +1), and an interpretation of the distal stimuli at some level of neural processing, but one that paradoxically escapes awareness and therefore, fixation of belief (each scored -1). An external object may, but is not required to, create a subliminal percept (score 0). Despite demonstrable effects of subliminal on subsequent percepts, subjects claim to see nothing, as for example in metacontrast masking , in cont7, as indicated in Table 1.A ‘mental image’ is a sight or sound that reproduces an object of perception, or combines such objects in an agglutinative fashion, from memory – thus, in the absence of a distal stimulus (score -1). There is no belief in the external reality of the image (score -1): if one believed in it, one would be hallucinating. There needs to be some proximal stimulus, although it may be distant from the resulting mental image, as when the mere feel of a carpet triggers an image of the carpet in front of a fireplace with a cat asleep on it (score +1), to account for the ‘concrete’ nature of the image . In Reid’s view, Ganzfeld is a uniform fog, in which visual stimulation by light is too even for distinct objects to be visible. The auditory equivalent would be white or pink noise; in both cases, there is a proximal stimulus (score +1). The Eigengrau corresponds to the internal level of uniform stimulation generated in the eye , independent of proximal stimulation (scored 0). A distal stimulus, an external object, and belief in external reality are contra-indicated for both categories (scored -1). One is aware of a Ganzfeld (score 1), but not necessarily of the Eigengrau (score 0). Both categories may seem esoteric, but have proven important in visual science since Fechner, and so have a place in Table 1.A Table 1.At an opposite extreme from perception is ‘fancy,’ or pure imagination, in which the mind invents visions or sounds unrestricted by reality that can be summoned or dismissed at will . Such faTable 1 illuminates a useful vocabulary of mental states, and perhaps offer up some new insights.As already stated, we scored each property in the same direction, with 1 representing reality and -1 fancy. The use of a scoring scheme for mental categories is novel and admittedly debatable, and using a ternary score  may improve on a simple binary  logic but still ignores degrees of uncertainty. However, a score sheet such as Table 1, one may look for numerical patterns within them. Table 2 provides an index of how different the categories are from each other. Diagonal elements in this Table are all zero since categories do not differ from themselves, and the upper triangle is redundant, being a reflection of the lower one. Each entry is the root-mean square (RMS), that is, the square root of the mean squared differences between categories, the mean being taken over the five properties. RMS values are scaled to lie between 0 and 1 by dividing by the maximum possible value. The initial squaring ensures that positive and negative differences count equally instead of canceling. To illustrate from the first column, since perception and affordance differ little, RMS is small (0.22); since perception and mental imagery differ more, the index is higher (0.67). Perception and fancy differ maximally (1.0). The RMS values point toward a more nuanced conceptual landscape than provided by a simple same/different analysis.Given the scores in Table 3 compares the categories, not in absolute units like RMS, but rather in terms of variability, since scores that differ absolutely may nevertheless co-vary: for example, each Ganzfeld score equals 1+ twice the corresponding Eigengrau score. Table 3 is the variance/co-variance matrix, in which diagonal elements  are variances and values below the diagonal are co-variances; perception and fancy, being constant with no variance, are excluded. Table 4 extracts from Table 3 the proportion of variance in each category ‘accounted for’ by each other category, as indexed by r2. This is the square of Pearson’s correlation coefficient, r, and equals the ratio of the covariance to the geometrical mean of the two category variances. Using this metric, which is standard in statistics, the variance accounted for lies between 0% (no relation) and 100% (entirely predictive). Table 4 shows how much the categories predict each other, r2 being 100% between Ganzfeld and Eigengrau and greater than 40% for 7 other pairs (bold-face in Table 4). In the remaining cases r2 is small, indicating that these categories approach statistical independence (r = 0). To the extent independence holds, the mean score for each category provides a measure for that category which is uncontaminated by the other categories. Mean scores are provided in Table 1 and plotted against category in Figure 1. These means agree well with the authors’ intuitions concerning realism; the higher the mean score, the more reality-based the category.Subsequent Tables present more advanced statistical comparisons. r2, taken across all 11 categories. Table 5 shows how the properties inter-relate; most of the r2-values are satisfyingly low, implying near-independence of the properties, with only one pair  with an r2 over 40%.Similarly, one can also ask if the five properties (rather than the categories) are distinct or not. This can be answered by calculating the variance in each property accounted for by each other property, again expressed as Table 1 index the essential elements in this process, and so are reasonably complete in this sense. However, Table 1 ignores interactions among categories – Wagner could compose music (fancy) only when he could touch velvet (sensation) – and ignores the role of feedback, i.e., the effects of attention, expectation, and memory on perception. Table 1 also says nothing about how action controls on-going environmental information pick-up  since the brain must correct sensations that have been distorted by the sensory organ , but to the extent that the corrections are good, the final outcome will correspond to reality. Therefore, perceptual illusions are ultimately in the same general category as percepts, and should best be thought of as a sub-category of perception. They do not lead to delusions but rather permit the perceptual system to produce to best perceptual hypothesis possible when stimuli are incomplete and ambiguous . Remaining distortions like the water-color effect, though remarkable, are generally of small magnitude and probably do not affect adaptive visual behavior.In ’ effect . In the ’ effect . But in Table 1. Thus darker colors illicit somber moods and lighter colors more cheerful ones; saturated colors (red) elicit different moods than desaturated ones (pink). Mental associations between specific colors and specific perceptions are readily made, as a pool of red color on the tarmac may be perceived as blood even when it is paint. Interactions of this sort speak to a larger frame of reference in which emotion and feeling tone are included, as well as sensation, action, imagination, and perception.In Reid’s common-sense philosophy, perception, sensation, and emotion are distinct; perception provides knowledge, whereas sensation can trigger emotion and disrupt knowledge. Modern psychology has no overarching theory of emotion/perception interactions, but it does have an enormous accumulation of examples of such interactions, all ignored in Ideally our analysis of Reid’s philosophical approach to perception remains true to the Common Sense School’s goal of establishing useful categories. A key outcome of our analysis is that the processes by which we perceive stimuli can be grouped into different categories with different scores for various properties, according to Reid’s own definition of perception. We recognize that these categories and properties may need further expansion to go beyond vision and help us to better understand the other senses and especially multimodal perception, that is to characterize the conditions under which stimuli combine effectively. This may eventually lead us to redefine Reid’s idea of ‘perception’ in terms of the observable product of signal reception, integration, and processing in a larger realm than just the visual one on which our analysis was focused. Whether or not ‘multi-perceptual’ and ‘multisensory’ systems will turn out to differ in the ways that we claim visual perception and sensation to differ will become clearer as multisensory research progresses. Most important, clarifying terms should both aid empirical research and facilitate communication between philosophers and scientists. Finally, we rather hesitantly have put forward an example of what me might call ‘computational philosophy,’ in which a perhaps simplistic ternary scoring system permits statistical analysis, with the hope that others may take advantage of this approach when appropriate for other philosophically inspired treatments of mental states.AR wrote the initial paper. BD-L provided philosophical insights and corrections.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


MBW) is a pulmonary function test (PFT) that is used to infer lung function through measurement of ventilation heterogeneity (VH). However, the body position that a test is taken in may also influence VH, due to the “Slinky” effect of gravity on the lungs. In healthy subjects this has minimal effect, but in unhealthy groups, PFT outputs have been seen to change drastically with body position. In this study, we used a combined computational and clinical approach to better understand the response of outputs from the MBW to body position. A patient‐specific model of the MBW was developed, then validated against clinically measured washout data, as well as broader results in the literature. This model was then used to compare changes in MBW outputs with respect to body position, showing that output changes sensitively predict regional airway size differences between lobes. We then highlight cases in which body position effects may bias MBW outputs, leading to elevated or masked responses to bronchoconstriction. We close by placing this result in context with broader clinical practice, and showing how it can help improve interpretation of test outputs.Multiple‐breath washout ( The conducting zone of the human lungs typically consists of 16‐17 generations of bifurcating airways, subtending into approximately 130 000 terminal bronchioles. Distally, the left and right main bronchus bifurcate, and feed into 5 distinct lobes of uneven size. In diseases such as asthma, inflammation and mucus secretion cause the conducting airways to narrow, leading to strongly heterogeneous flow. Clinically, this flow heterogeneity is measured through at‐the‐mouth pulmonary function tests (PFTs) such as spirometry, oscillometry and inert‐gas washouts  than in the right lung, the patient was classified as having “Right” regionalization, and vice versa as “Left”. Similarly, if the mean small airway size in the lower lobes was significantly larger than in the upper lobes, the patient was classified as “Upper”, and vice versa as “Lower”. If no significant difference in airway size was seen, the structure was classified as having “Neither” regionalization.Each virtual structure also had its degree of disease regionalization classified, by comparing mean small airway sizes at various locations. If the mean small airway size in the left lung was significant larger  was used to drive a convection‐diffusion transport model for gas concentration  using a finite difference method in MATLAB. Initially the lungs were started with no gas concentration, and the model was used to simulate a wash‐in, until exhaled gas concentrations stabilized (changed by less than 0.5%) over consecutive breaths. Following this, the washout was simulated over multiple consecutive breaths, until the mean exhaled gas concentrations fell below 1/40th of the mean exhaled concentration from the first washout breath. From each washout curve, scond and LCI were calculated. Due to the simplicity of the respiratory zone in this model, the MBW output sacin was not simulated, as it is known to respond to diffusive effects in the respiratory zone , and without gravity. Each washout was performed using gas properties consistent with an To apply the computational model in a way that is relevant clinically, we use a multi‐step validation process. The model is first validated directly against clinical data. Following this, comparisons to broader findings in the literature are made, to validate against aspects for which there is no available structure specific clinical data. The model is then used to investigate the effects of body position on the inert‐gas washout.scond values (standing) against the corresponding clinical measurements. Both measures can be seen to have a significant positive correlation with clinical data, of strong statistical significance (P ≪ 0.05), with R2 values of 0.51 and 0.57, respectively. The Bland–Altman plots indicate that scond in particular is being well captured by the model, with little bias (0.005), constant variance, and the 95% confidence interval . LCI still maintains a good fit, but is clearly more variable than that of scond, with larger bias (0.66), and 95% confidence interval . LCI potentially also has a slight positive correlation in the Bland–Altman plot.In Figure It can be noted in Figure Patient‐specific clinical data was only obtained in one body position (sitting). To validate the gravitational component of our model, we compare outputs to the broader literature. In Figure The results in Figure −1 for supine, prone, left‐lateral, right‐lateral, and orthostatic, respectively. We note that the value for supine is in line with the clinically measured value reported by Horn et al.  than LCI (prone), we take this as predictive of “Upper” classification (as supine best ventilates the lower lobes). We make similar predictions for “Lower”, “Left”, “Right”, and “Neither”, using both LCI and scond.We hypothesize that MBW outputs exhibit consistent and predictable changes as body position is altered, and that these changes are driven by regionalization in the patient's underlying lung morphology. To test this hypothesis, we predict regionalization (as classified in the methods section), based on the change in test indices from opposing body positions. We expect MBW outputs to be healthiest (lowest) when taken from a body position that best ventilates the most constricted region. Considering the Slinky effect, we can expect each position to best ventilate the most gravitationally low region. Thus, if LCI (supine) is significant greater , and the subject FRC. This highlights the mechanics that the MBW is most strongly responding to. The virtual structures are physically accurate to generations 6–10, relying on algorithmic generation and extrapolation of airway radii beyond this point. Despite the algorithmic component, the asthmatic structures were shown to have significantly higher total resistances, as well as smaller and more varied homothety ratios (in the segmented airways) (Bordas et al. The results in Figure scond. As body position is changed to preference a more constricted region, flow rates to that region will increase. In healthy subjects, flow rates into each of the lobes are already quite high, meaning the change has a negligible effect, leading to minimal changes in LCI or scond. However, in a patient with regionalized bronchoconstriction, flow rates will be lowest in the constricted region (a phenomena which was partially investigated in our prior work (Foy et al. scond, and a larger change in MBW outputs between positions.The response occurred consistently for both LCI and The fact that body position can affect MBW outputs is not on its own a novel contribution. As early as 1966, Bryan et al.  have conO2 between left‐lateral and right‐lateral. The results that we have presented extend upon and broader this idea, providing a more strongly quantitative interpretation of the phenomena.However, studies of unhealthy patient groups have shown both drastic increases and decreases, with little explanation of why (Attinger et al. In clinical settings PFTs are rarely performed in lateral or prone positions, predominantly being performed either upright or in supine. Due to the diagonal nature of the oblique fissure, these two positions produce similar relative ventilation patterns Fig. . This suFurthermore, while relative ventilation is similar between supine and upright, it is not identical, with the right‐middle lobe being most significantly affected. This means that for specific disease cases, the response in MBW outputs may be quite different. We illustrate this by considering LCI changes from sitting to supine across the entire patient group, and specifically in 3 distinct cases Fig. . As showTo the best of our knowledge, this is the first combined computational‐clinical study to investigate this phenomenon. Through the use of modeling, we can more precisely investigate the function‐form relationship, and give strength to the interpretation of the effect of body position. Beyond this, the results suggest the potential for clinical utility. In clinical literature there is disagreement over when different positions should be used to mechanically ventilate patients (Thomas and Paratz The model outlined in this study is intended as a tool to improve understanding of the function‐form relationships involved between MBW outputs and lung morphology. While the model was strongly validated, there were a few phenomena that it did not account for, in particular these were a lack of airway dynamism throughout the breathing cycle, the assumption of static compliance, and the simplistic nature of respiratory zone structures. Each of these simplifications would lead to an underestimation of flow resistance, and in particular would have contributed to the slight negative bias of the model seen in Figure The virtual structures used in this study also rely in part on algorithmic generation of small airways. The airway sizes below generation 10 are not necessarily specifically representative of the patient, but instead an extrapolation from the airway sizes measurable from CT segmentation. This means that the models only capture airway asymmetry that originates above generation 10. Given the strong correlations of the model with clinical data, we do not believe that this represents an issue in interpretation of study results. However, the consistency in airway decrease in the lower generations may have led to a reduction in overall noise within the results, leading to stronger results than would be seen clinically.The study was performed with a large number of asthmatics (Kaneko et al. Finally, it should be noted that by its nature, the MBW does not assess regions of the lung affected by airway closure, and as such, these effects were not quantified in the current study (except briefly in the results in Figure These results are intended as a groundwork for future investigations. They suggest two major ideas. First, that MBW outputs may under or over‐predict lung disease in patients with strong disease regionalization. This means that for some patient groups, it may be more appropriate to measure lung function from non‐standard positions, to overcome this bias. Second, that information about regionalization may be gained by comparing MBW outputs from opposing positions. In future work, we aim to investigate more directly how these insights can be applied to improve clinical outcomes for patients.In summary, we have used both clinical and computational data to improve understanding of how MBW outputs may be affected by body position. As body position is changed the relative ventilation of each lobe is also changed, due to shifts in the gravitational ventilation gradient. This shift has minimal effect in healthy patient groups, but creates a bias that can significantly change MBW outputs in unhealthy patient groups, particularly those with disease regionalization. The effect that body position has on MBW outputs appears to be consistent and interpretable. This means that the biases of each of the positions can potentially be understood and accounted for in clinical settings.CB has received research grants and consultancy from GSK AZ/MedImmune, Novartis, Chiesi, Pfizer, Vectura, Theravance, BI, Roche/Genetech.