Journal of Integrative Research & ReflectionVolume I: Spring 2018
Journal of Integrative Research & ReflectionVolume I|Spring 2018Editor in ChiefBronwyn McIlroy-YoungEditorial BoardHannah AndersonKatrina BrainNess LamontJournal Management TeamSarah MatthewsKaitlin Ollivier-GoochYousuf RamahiVictoria ShiTheJournal of Integrative Research & Reflection(JIRR) is a free undergraduate student journalpublished by the Department of Knowledge Integration at the University of Waterloo. The copyrightof all contributions remains with their authors. All else,©2018 JIRR.ISSN: 2561-8024journal.IRR@outlook.com|jirr.caUniversity of Waterloo, 200 University Avenue W, Waterloo, ON N2L 2G1
ReviewersJillian AndersonFindley DunnHannah GardinerAlex PearceLuiza AraujoCaroline DuntonMorgan GittDivya PrasadBrendan BatlinerHaley HarringtonRachael GregorisSamir ReynoldsAnna BuhrmannAnita HodorRachael LaroseKuil SchoneveldJames ButlerErin HoganJasmine ManszVictoria ShiSukhi ChuhanCheryl JosephBenjamin MillerMary TressAndrew ClubineEric KennedyKaitlin Ollivier-GoochSpencer WilliamsHannah CollinsonArnold KwokAnthony PicardCover art credit to Karissa Van Muyen, a Fine Arts student at the University of Waterloo. Thispiece was shot and manipulated by the artist as a part their photo series entitledSubmersion.We acknowledge that we work and learn on the traditional territory of the Attawandaron (Neu-tral), Anishnaabeg, and Haudenosaunee peoples. The University of Waterloo is situated on theHaldimand Tract, land promised and given to Six Nations, which includes six miles on each side ofthe Grand River.2
ContentsWelcomeBronwyn McIlroy-Young. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6Medical Service Trips in Nepal: A Short-Term Remedy with Long-Term ConsequencesParnika Godkhindi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-18The Value of Interactional Expertise: Perceptions of Laypeople, Interactional Experts,and Contributory ExpertsMaytal Perlman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-26The Deterrent Effects of Corporate Punishment: Restoring the Broken Image of thePharmaceutical IndustryEmily Wong. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-36Stolen Trophies: Hunting in Africa Perpetuates Neo-Colonial Attitudes and is anIneffective Conservation ToolMeghan Bird. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-46Assessing How the Zika Virus Induces Apoptosis and Cell Disruption in Neural Pre-cursor Cells, and Societal Impacts of Zika: A ReviewMeng Ji. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47-63The Blurring of Identity: Cochlear Implants and the Deaf CommunityZo ́e Bernicchia-Freeman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64-74Racism in the Harry Potter SeriesKaitlin Ollivier-Gooch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75-803
WelcomeInterdisciplinarity has become an increasingly popular buzzword in academia. It is posited,without elaboration, as a desirable process or state for education and research. But the term lacksspecificity: Can it be practised from within traditional disciplines or does it call for a more radicalupset of established structures? Does it refer to the products of research, the institutions whichenable knowledge creation, or the social practices and identities that are formed within and arounddisciplines? More foundationally, what defines an academic discipline? Where are the epistemicboundaries that interdisciplinary work claims to transcend?1Do they exclude any knowledge housedoutside of academic institutions; or, does interdisciplinarity suggest a possibility for new forms ofresearch which attend to a greater range of ways of knowing about the world?More often than not, the term seems to be used in a shallow sense—taking the products ofdisciplinary research and laying them side by side, without integrating the perspectives, aims, ormethods of diverse ways of knowing. We created theJournal of Integrative Research & Reflection(JIRR) with the aim of facilitating deep, critical engagement with interdisciplinarity, in addition toways of knowing informed by identity and lived experiences. As such, JIRR is a cross-disciplinaryjournal; we are interested in research and discussion across diverse domains of knowledge, notjust those currently deemed credible by the academy. As a journal, JIRR provides an open-accessplatform for cross-disciplinary work done by undergraduate studentsbe it applied research whichemploys multiple ways of knowing, creative projects that disrupt disciplinary boundaries, or theo-retical work on cross-disciplinarity in undergraduate education. By providing this space, we hopeto encourage young scholars to reflect critically on the methods, aims and paradigms of disciplinaryand interdisciplinary projects. Through the creation of this journal, we are building a communityof cross-disciplinarians across faculties, campuses and levels of expertise.Work on JIRR began in winter of 2017 with a small team of Knowledge Integration studentsat the University of Waterloo. This team, now our Editorial Board, identified a gap in publish-ing opportunities for undergraduate students at our university. We recognized that undergraduatepublishing creates value for students through encouraging them to engage with their work as schol-ars and allowing for learning about peer-review, a foundational structure of the academic researchcommunity. Cross-disciplinarity was a natural choice of focus for our journal. The Department ofKnowledge Integration is a center of expertise in cross-disciplinarity, providing us with access toadvisors and other information resources for developing the journal.Our choice of focus for the journal presented unique challenges: there were few precedents forpeer-reviewing and evaluating integrative cross-disciplinary work. The editorial team spent muchof our first year developing an understanding of existing theory on cross and interdisciplinarity,including research from philosophy of science, pedagogy and social epistemology. We integratedthese perspectives to create a unique, double-blind review process for cross-disciplinary projects.This includes an evaluation framework that accommodates for cross-disciplinary projects of a broadrange of mediums and a peer review process that leverages our reviewers’ diverse expertise and lev-1Krishnan, A., (2009). What are Academic Disciplines: Some observations on the Disciplinarity vs. Interdisci-plinarity Debate. ESRC National Centre for Research Methods.4
els of study. The process was also designed so as to provide training for inexperienced reviewers.Our months of preparation paid off and we celebrated a very successful first edition. As acommunity building project, JIRR exceeded our expectations: over 60 people, including editors,authors, reviewers and advisors, from all levels of study and across Canada and the U.S., cametogether to realize our first edition. We received 20 submissions, of which eight were selected forpublication (including the artwork depicted on our cover). Each of the articles explores a uniquetopic through multiple disciplinary lenses; some pieces also consider ways of knowing derived fromsocial identity and stakeholder knowledge. We congratulate the authors for their talent and theirdedication to a challenging project. The following works begin the process of interdisciplinary in-quirythey do not answer the wicked questions posed above; but, their creation and developmentin collaboration with the JIRR team fostered countless discussions, between authors, editors, andreviewers, about the theory and practice of cross-disciplinarity. Through this process, we have cometo recognize the challenge of creating work that steps outside of and reflects back on disciplinaryresearch. This new understanding reinforces our belief in the importance of beginning conversationabout these topics at the undergraduate level.This edition of JIRR is our first step. We have created a roadmap, and illuminated countlessopportunities for growth. In future years, we hope to expand our reach to more students in moreschools around North America. And, to improve our communication around cross-disciplinarity,integration and social epistemology, in hopes that stronger communication of our vision will trans-late to submissions that engage more deeply with these concepts. We also aim to strengthen theJIRR community through creating more opportunities for connections between supporters.We hope you enjoy reading our inaugural edition of theJournal of Integrative Research & Re-flection, and that you return to follow the growth of our project, and community, for many yearsto come.Sincerely,Bronwyn McIlroy-Young,Editor in Chief5
JIRR gratefully acknowledges the support of the Waterloo Environment Students Endowment Fundand the Department of Knowledge Integration in the production of JIRR, with special thanks toRob Gorbet for mentoring the Editorial Board from our journal’s inception to its publishing. JIRRalso thanks William Kirk Roy for helping us to navigate the peer review and publishing process.Finally, we would like to thank the Combining 2 Cultures 2018 conference for their assistancewith JIRR outreach and their work towards our shared vision of promoting interdisciplinarity inundergraduate education.6
Medical Service Trips in Nepal: A Short-Term Remedy withLong-Term ConsequencesParnika GodkhindiIntroductionNepal is known for having one of the poor-est health systems in the world-it struggles withhigh rates of infant mortality and disease out-breaks (World Health Organization 1), which areonly exacerbated by poor sanitation, malnutri-tion, and inadequate water supply (Ministry ofHealth & Population 45). The country’s moun-tainous terrain and uneven population distribu-tion isolate the rural areas, where the nation’spoorest citizens live. Achieving universal andequitable health care has therefore been verydifficult (Mishra et al. 3).Despite foreign aid and bids by the gov-ernment, there is little incentive for healthcarepractitioners (HCPs) to work in the country’ssecluded rural regions (Zimmerman et al. 65).As a result, Nepal only has 0.67 doctors, nurses,and midwives per 1000 population (Ministry ofHealth & Population 4), which is significantlylower than the World Health Organization’s rec-ommendation of 2.3 doctors, nurses, and mid-wives per 1000 population. The country’s percapita healthcare expenditure remains one of thelowest in the world, at just$4.06 USD per annumas of 2014 (WHO 11). Many non-governmentalorganizations (NGOs) have endeavored to ad-dress the shortcomings in the Nepalese health-7
care system, predominantly focusing their ef-forts in rural and remote areas. There are cur-rently over 875 health-focused NGOs operatingin Nepal (Karkee et al. 2). An increasing numberof them are coordinating medical service trips(MSTs), in which individuals from the GlobalNorth participate in short-term health-relatedvolunteering in the country (Citrin 12).Whether MSTs are truly helping theNepalese healthcare system is heavily contested,and there is limited empirical research on theimpacts of MSTs on the local community. Thispaper will integrate theories from multiple dis-ciplines to consider the potential benefits andconsequences of short-term MSTs, as well as theunique socioeconomic determinants of health inNepal. It will consult academic papers on de-velopment theory, in addition to interviews andlived experiences of individuals accessing health-care in Nepal. Beyond analyzing the Nepalesehealth care system in isolation, this paper willalso discuss the mentalities, financial motiva-tions, political aims, and competitive factorsthat drive NGO development in Nepal. Thisqualitative overview will allow for a criticalassessment of MST operations in the country,helping ascertain that MSTs in Nepal are doingmore harm than good. Not only are they hinder-ing development of the local healthcare system,they are also endangering the immediate healthoutcomes of their patients. Accordingly, moreresearch is required to find structures of MSTsthat will better serve Nepal’s current healthneeds, while also contributing to its long-termdevelopmental goals.Brief History of Health Care in NepalNepal is one of the poorest countries in theworld, with great income inequality between therich and the poor (Niraula 151). While wealthiercitizens live close to urban centers, the major-ity of the population lives in remote and ruralregions of the country, where subsistence farm-ing is the predominant livelihood (Ministry ofAgricultural Development 4).The people inthese areas are of a diverse range of caste, lan-guage, and religion. For such a small country,Nepal is remarkably varied in its landscape anddemographics; this often introduces complexi-ties when trying to implement any system-widechange.To support development, Nepal has receivedaid from numerous countries, namely the UnitedStates, India, and China. However, political mo-tives have been a major priority for these donors.After the Chinese revolution in 1946, the UnitedStates provided monetary aid to Nepal and her-alded an anti-communist movement; due to itshigh levels of poverty and physical proximity toChina, Nepal was deemed to be especially vul-nerable to communism (Khadka 78). Althoughthis influence from the U.S. helped Nepal sus-tain its monarchy, more Nepalese people beganto support communism, leading to the formationof a national communist party in 1949 (Gul 30).By the late 1970s, Nepal needed loans to sus-tain its fragile economy and pay back existingdebt to Western countries, especially the U.S.(Regmi 192). The World Bank provided “tiedaid”, recommending that Nepal cut its govern-ment spending on public services like healthcare (193). In 1980, the International Mone-tary Fund provided further funding through itsstructural adjustment programs, which cappedpublic expenditures and pushed for a greaterfocus on more “cost-effective” and “less politi-cal” strategies of health care, such as “vertical”and “disease-focused” interventions (Citrin 38),rather than those which addressed other deter-minants of health, like poverty or infrastructure.Accordingly, the government began to decreaseits public health spending. As a result, there arefewer state-owned health enterprises than everbefore, and the private health sector has grownconsiderably (Adhikari et al. 69).Lack of funding and resources for theNepalese health system can also be partiallyattributed to the People’s War, a civil conflictthat lasted from 1996 to 2006 (Baral and Heinen2). Much of the conflict occurred in mountain-ous regions of the north, so the war’s damagewas primarily endured by rural folk, many of8
whom were displaced from their homes (WHO1). Today, Nepal is still suffering from the crum-bling infrastructure and decimated roads thatresulted from use of land mines during the war(Shneiderman and Turin 145).After the People’s War, the old autocraticgovernment was replaced by a republic withina multi-party system (Poudyal 159), but con-cerns of political instability remained. Bearingin mind the risk of any future insurgencies, thecountry shifted the focus of its health policy to-wards decentralization and localization of med-ical technologies; this way, potential politicalunrest could only have a limited impact on theprovision of health services (3). The governmentbegan to devolve its funds to local bodies to min-imize risks (12), giving community organizationsand NGOs more autonomy.Nepal’s Pluralistic Health SystemDue to the previously mentioned economicliberalization policies and civil conflict, Nepal’shealth system is highly fragmented.Publichealth care receives limited funding, and theprivate health sector primarily serves urban cen-ters (Saito et al. 818). Both public and pri-vate health care are subdivisions of “modern” or“Western” medicine, but other forms of medicineexist as well, including folk medicine (e.g. witchdoctors, faith healers) and traditional medicine(e.g. Ayurveda, Homeopathy) (Subedi, “Pri-mary Health Care” 323). In rural parts of thecountry, the latter are more widely used andtrusted than modern forms of medicine; studiesindicate that this is because they are “sociallyand culturally closer to the people, whereas mod-ern health care has been criticized for beingunacceptable and unsatisfying to most of thepopulation” (Subedi, “Modern Health Services”412). When dealing with an illness, patientswant not only a cure, but also a meaning be-hind the experience of the sickness itself (413).While folk and traditional medicines serve bothof these functions, modern medicine addressesonly the first.People in rural areas are also distrustful of lo-cal HCPs because they believe that preferentialtreatment is given to those of a higher caste. Ina case study at a rural health post, a respondentclaimed that higher-caste, influential patientsreceived “most of the time of the health poststaff” as well as “free medicine”, while the poorwere simply directed to “buy from the shop”(Niraula 157). As a result, modern medicineand primary health care offered through healthposts are generally seen as a “last resort”, andover three-quarters of all ailments in the countryare treated by the alternative systems (Subedi,“Modern Health Services” 413).Moreover, modern medicine is less accessiblethan its alternatives, as the journey to healthposts can be treacherous for rural folk. Nepalhas “scattered rural roads networks,” and the“rugged, harsh, and diverse” terrain in ruralregions makes long travels dangerous (Bhan-dari 8). Land mines used during the People’sWar (Shneiderman and Turin 145), as well asthe recent earthquake in 2015 left many roadsirreparably damaged. Landslides are commonoccurrences (Petley et al. 40), and inclementweather puts travellers’ safety at risk (Gentleand Maraseni 32).Modern medicine is also the most expensiveform of care, as the increased privatization of ser-vices has rendered health care and medicationsunaffordable for poorer individuals. They there-fore rely on subsidized public institutions for themajority of their healthcare needs, but even thestate-run health posts can be costly. Althoughuniversal public health care was introduced in2007, it covers only basic health services and ac-cess to 40 essential drugs (Ministry of Health &Population 8). As a result, out-of-pocket health-care expenses by individual households remaintremendously high, accounting for over 62.5% ofthe countrys health financing (WHO 46). Theseuser fees serve as another barrier to the use ofmodern medicine and equitable health care ac-cess in Nepal.The locals’ dislike of modern medicine athealth posts, as well as difficult standards ofliving in rural areas, mean that HCPs are dis-9
inclined to work in rural regions of the country.Privatization is also weakening the public healthsystem, because a “brain drain” is occurring aseducated citizens of the country are repelled frompublic service and are drawn towards working inthe more lucrative private sector (Nichter 669).Consequently, public health services lack coor-dination, are inadequately sourced and under-staffed, and have inefficient bureaucratic struc-tures (Mishra et al. 1).The Role of the NGOThe shortcomings of Nepal’s government-funded modern health system necessitate theoperation of numerous health-oriented NGOs inthe country. These NGOs vary in scope, struc-ture, and size (Sherraden et al. 396), but aresimilar in aim: to better meet the medical needsof rural communities in Nepal.Increasingly,local NGOs are partnering with organizationsfrom other countries to receive international vol-unteers, who then help provide care to Nepalesepeople. Especially popular are short-term med-ical service trips (MSTs), which allow foreignHCPs to travel overseas to the Global Southand provide medical services for days or weeksat a time (Asgary and Junck 625).Medicalprofessionals bring specialized skills and expen-sive equipment that can be very helpful to low-resource regions.The most obvious benefits of MSTs are accessto “highly-trained specialists” and “proceduresnot always possible within local infrastructure”(Green et al. 11). Specialized medical servicescan be offered in a timely manner, thereby sav-ing citizens’ lives (Citrin 14). In addition, MSTsfacilitate the exchange of knowledge and skillsbetween local and foreign health workers, andthus have the potential to improve the qualityof domestic care (Dixit et al. 414).Implications of MSTsOne critique of MSTs is that an inherentpower imbalance exists when NGOs operatewithin a country of the Global South. Interna-tional volunteering can be considered a one-wayexchange of goods and services, in which thesending country is the sole provider, and the re-ceiving country is the sole benefactor. Yet, “vol-unteering as ‘service’ tends to reinforce powerdifferences between giver and receiver” (Loughand Oppenheim 198). This means that the hostcountry largely has little to no control when aninternational NGO attempts to operate within it.As a result, the foreign NGO often has completefreedom when deciding where in the countryto send its aid, and to whom to give it (Bauer3). In Nepal, this has resulted in a clusteringof volunteer positions and NGO health projectsin popular tourist areas, due to their “exotic”allure and appeal (Citrin 52).The localization of NGO projects within thesame region further introduces problems.Acase study in the Humla district of Nepal foundthat there was a complete lack of coordinationbetween NGOs operating within the region, asthey would avoid working with each other forwant of more autonomy and control (Citrin 39).In consequence, health services were frequentlyduplicated, or they nullified each others effec-tiveness. This resulted in further fragmentationof health care delivery, diminishing the qualityof care that was provided to individuals (40).The supersaturation of NGOs in certain lo-calities also perpetuates cycles of inequality inhost communities, as the input of foreign cap-ital takes pressure off the local government toinvest in its health care.A case study con-ducted of MSTs in Ghana found that when de-ciding where to invest money to improve healthcare, the Ghanaian government first consideredthe number of existing NGO services alreadyin the area, regardless of their quality (Greenet al. 6). Given that Ghana and Nepal havesimilar health systems with medical personnelshortages in rural areas (Drislane et al. 325),similarly structured health insurance systems(Saleh 107), and influence from NGOs (48), it isnot unreasonable to expect that the same phe-nomenon occurs in Nepal. As a result, havingmultiple NGO health projects operating withinthe same locality in Nepal only impedes health10
development. Evidently, MSTs increase the hostcountry’s dependency on foreign humanitarianaid and are thereby weakening Nepal’s healthsystem (Asgary and Junck 627).Moreover, the same case study of an NGOin the Humla district found that NGO projectstend to be “highly performative” because theyare greatly publicized. There are often domesticand international film crews present, so NGO op-erations are frequently brought to public atten-tion. It is not uncommon to find local politiciansand prominent figures speaking at opening andclosing ceremonies, idealizing what the NGO willaccomplish (Citrin 45). Such displays continueunchecked because no formal systems currentlyexist which can evaluate the actual impact ofMSTs. NGOs themselves are unmotivated todevelop and conduct objective analyses of theiroperations-in part because this is logistically dif-ficult, but mainly because NGOs run on fundsfrom donors (Suchdev et al. 47). They feel pres-sure to prove the magnitude of their impact, andto do so positively in order to continue receivingdonations. In an attempt to substantiate theirwork, NGOs resort to maximizing the numberof patients seen, surgeries performed, and drugsadministered (Bauer 8). However, donors are“unaware that these numbers mean little in theoverall context of a poverty-driven health sta-tus,” (9) since having access to health care doesnot automatically imply that an individual is‘healthy’.The difference between ‘health’ and ‘healthcare’ is especially relevant in the Nepalese healthsystem, where there is great emphasis on dis-pensing medication to outpatients (Citrin 57), asopposed to addressing the root causes of healthproblems. The current ‘fee-for-service’ systemlacks regulation and encourages pharmacists andlocal HCPs to over-prescribe medications; afterall, the more medicines are sold, the more moneythey will make. Because drugs are short-term in-terventions that are costlier to deliver and easierto market to patients, they are more profitable(Maru and Uprety). Therefore, medications dis-courage longitudinal and preventive approachesto medicine.When MSTs administer as many drugs aspossible to prove their efficacy, this only perpet-uates the short-sighted, problematic obsessionwith drugs in Nepal. It encourages what Whyteet al. call a “medicalization of health”: whenmedicine is used to “solve the problems thatshould be addressed in other ways” (5). In fact,the prospect of free medicine is the very reasonthat many rural patients make the long journeyto NGO health camps. Citrin suggests that atrural health posts, medications are “symbolic”of more than a cure: they provide an oppor-tunity to connect with people who care andcan “confirm and legitimize sickness and bodilydiscomfort,” thereby providing underprivilegedpeople with hope (47). However, this weakensthe local health system, as it fosters locals’ glo-rification of Western approaches to medicine.Although modern medicine is often consideredthe “last resort” in Nepal’s pluralist health sys-tem (Subedi 323), the allure of foreign medicineis enough to attract locals’ attention. Then, theWestern paradigm “competes with, rather thansupports, local health strategies,” (Bauer 4) aslocal residents place more faith in the health careprovided by a foreign HCP than a local HCP.They will wait for the next arrival of free healthcare from an MST, rather than consulting localmedical personnel for even a minimal cost.Not only do local citizens distrust local healthworkers, but the ‘Western savior complex’ alsocauses many international volunteers on MSTs tounderestimate their local counterparts (Roberts1491). This misunderstanding may stem fromthe fact that many local health workers inNepal are “female community health volunteers”(FCHVs) who do not have traditional medicaldegrees (Khanal et al. 256). Even so, FCHVsare competent and key to local health centers(Khatri et al. 1). They provide services thatwould elsewhere be undertaken by professionalHCPs, including childbirth assistance, medica-tion distribution, and provision of emergencycontraception (Panday et al. 9). Moreover, localhealth care professionals do have medical degrees11
and extensive training (Dixit and Marahatta 16).When these local HCPs are undermined and un-derestimated, both by local patients and foreignvolunteers, they become disheartened.Manymay choose to leave rural areas and practice inregions without NGO operations (Bauer 4), ren-dering certain areas further depleted of healthresources and in need of more foreign volunteers.A Short-Term RemedyHealth camps in Nepal have long been re-garded as solely short-term establishments. Dur-ing the People’s War, Maoists raided healthposts, evicted NGOs, and antagonized healthprojects (Singh 1499). Land mines were plantedthroughout the countryside, which destroyedroads and hindered the distribution of medicines,as well as access to rural health posts. Becauseof the constant threat, health posts increasinglyadopted short-term approaches to health careprovision (Citrin 40), limiting their ability toeffectively provide continued care for patients.This temporary role of health posts is also pre-senting itself in the operations of MSTs, whichrange from just one week to three months induration (Citrin 12). However, this short-termapproach to health care encourages the previ-ously mentioned obsession with medication (57),and promotes immediate solutions to complexproblems. Such a mindset poses many threats tothe wellbeing of patients, diminishes the qualityof treatment, and hinders system development.Studies indicate that long-term volunteerplacements are more conducive to ‘capacitydevelopment,’ which is the improvement of acountry’s ability to achieve its own developmentobjectives over time. Placements lasting sev-eral months or longer are better able to fosterequitable partnerships between the sending or-ganization and host (Schech et al. 363), as theyallow for more collaboration and input from thelocal community. Since there are more opportu-nities for all stakeholders to contribute and havetheir say, long-term volunteering is more capa-ble of equalizing the power imbalance inherentin international volunteerism (Sherraden et al.401).In contrast, short-term placements are moreone-sided, less efficient, and interruptive of con-tinual service. They encourage more paternal-istic provision of care, as “when people do notexpect meaningful future interactions, they eas-ily justify taking advantage of the other party,”even subconsciously (Lough and Oppenheim204). Short-term volunteering has been shownto clearly benefit the volunteers, but impacts onthe host community are less clear (Sherraden etal. 405). From reviewing the evidence, it is clearthat the short-term nature of MSTs only exac-erbates their associated risks, further indictingthem.The short length of MSTs makes it easy toconflate volunteering overseas with going on abrief holiday. As it is, volunteer placements inNepal can easily be misconstrued to serve as acheap alternative to a ‘vacation’-the proximityof the Himalayas is attractive to those who wantto go backpacking or seek spiritual enlighten-ment. Nepal is often romanticized and exotified,so it is the perfect ‘destination’ for people look-ing to “do good” while travelling (Citrin 53).Consequently, international volunteers usuallyunderestimate the hardships of life in the coun-try, and do not realize exactly what they aresigning up for beforehand (Asgary and Junck626). In a qualitative study of an NGO calledPHASE Worldwide, international medical vol-unteers indicated that they felt “contextuallyna ̈ıve” in Nepal, despite having received “com-prehensive pre-placement briefings and docu-ments, and having had contact with previousvolunteers” (Elnawawy et al. 331). Consideringonly a fraction of sending organizations botherto brief their volunteers at all, most internationalvolunteers lack cultural understanding and areunprepared for the conditions in which they willbe working.This lack of cultural awareness can makeit difficult for international volunteers to prop-erly communicate with their patients. Nepal isincredibly diverse, and while the only official lan-guage is Nepali, there are 123 native languages12
(Central Bureau of Statistics 164). There is con-siderable variation in language, even betweenneighbouring villages, so international volun-teers rarely have a grasp of the local dialect.Although local HCPs may be present to helpwith translation, this is inconvenient and onlyslows down the health post’s operations (Greenet al. 11). As a result, even when a patientis clearly confused, it is not uncommon for for-eign HCPs to rush them along in order to see asmany patients as possible (Bauer 8). However,clear communication is very important in effec-tive health care, as misunderstandings can leadto misdiagnosis or incorrect treatment (5). Thelanguage barrier also makes it difficult to obtaininformed consent from the patient, putting pa-tient autonomy at risk (Roberts 1492).Furthermore, short-term MSTs are troublingbecause they do not demand accountability fromforeign HCPs. Since the visits are brief, patientshave very little opportunity to interact with thevolunteers; their time together is further short-ened by the volunteers’ rushing to see as manypatients as possible.Unless ailments can betreated entirely in one visit, short-term MSTsleave little to no opportunity for continuity ofcare. As a result, foreign HCPs do not follow upwith the patients they have seen and are con-sequently not held accountable for the servicesthey provide. This burdens the local healthcaresystem with providing follow-up care, should anycomplications arise once the volunteers are gone(Asgary and Junck 626). Therefore, MSTs canplace significant stress on local health workers,rather than helping them.The main concern regarding short-termMSTs is that they do nothing to tackle theroot cause of poor health in Nepal. Poor healthoutcomes are merely a symptom of much morecomplex systemic issues-poverty, education, andculture are just a few of the many determinantsof health (Chapman 19). Since MSTs are tem-porary and do not involve long-term initiativesto contribute to development, they are simply“band-aid” solutions. For instance, volunteersserving in the Karnali district of Nepal sharedconcerns that they were not making any realcontributions to improving Nepalese health, say-ing, “I cant help but wonder if I’m treatinghunger pains here,” and, “How do I tell peo-ple that their chronic pain comes from a life ofchronic work, which they cant stop because theirlivelihood depends on it?” (Citrin 56). Such ex-amples demonstrate the impermanence of anytreatments offered by foreign HCPs on MSTs.Even when they want to, volunteers are unableto involve themselves with activities that willspark long-lasting change in the area.The “Better Than Nothing” MentalityIf there are so many drawbacks and risksassociated with MSTs, why do they continueto operate so widely? Commonly, the role ofMSTs is justified with the argument that anyhealth care is “better than nothing,” even if itis not of the highest quality (Bauer 5). Withouta doubt, the health services provided by inter-national volunteers have saved countless lives(Asgary and Junck 629). However, it is likelythat just as many lives have also been hurt byMSTs. The “better than nothing” mentalityis damaging, as it introduces double standardsin the quality of care provided to patients inNepal. This makes it easy to sidestep regula-tions and encourages international volunteers tomake risky or unethical decisions in the name ofsaving as many lives as possible. Coupled withthe inherent power imbalance, this can be quitedangerous for Nepalese patients, as many blindlytrust foreign HCPs and do not doubt what theyare told.For instance, many sending organizationswill accept any and all applicants to volunteerwith them. Global health electives have becomeincreasingly popular in universities, so medicalstudents-and even undergraduate students-willvolunteer on MSTs (Asgary and Junck 625).They are often asked to perform services forwhich they have absolutely no training, such as“delivering babies, suturing wounds, or pullingteeth” (McCall and Iltis 290). Common mo-tives to volunteer abroad generally have little13
to do with helping the local community; manyMSTs are advertised to students as an opportu-nity to gain clinical experience, or as something‘unique’ to add to a resume (Projects AbroachInc.). Practicing medicine without proper train-ing would be unthinkable in the Global North,but the “better than nothing” principle justifiesit in low-resource settings. This puts patients atrisk, undervaluing life when it exists in poorersettings.Even professionally-trained foreign HCPsmay not have the skills required to practicein Nepal, and volunteers may feel pressured toperform services with which they are unfamil-iar. There is a big difference between practicingmedicine in a wealthy region, and in a poorsetting like Nepal.In remote regions of thecountry, there is limited access to “paper, med-ication. . . or reliable power and water” (Bauer4), let alone advanced medical technology. Yet,Western medical practice is highly reliant ontechnological aid for diagnosis and treatment(Giordano et al. 31), so HCPs without the clini-cal skills specific to low-resource health care mayfind it difficult to provide services as thoroughlyas they would at home.Despite the scarcity of resources, foreignHCPs often use diagnostic tests and tools ex-cessively, as they are generally unfamiliar withlocal ailments and want to “rule out” as manymedical conditions as possible in the shortestamount of time (Hozo and Djulbegovic 548).Doing so wastes resources in a setting with al-ready low supplies. Moreover, it can harbourcontentious relationships between the volunteersand local HCPs, who view the former as be-ing insensitive to the value of medical resources(Elnawawy et al. 332). While long-term interna-tional volunteers may adapt their skills to a newenvironment over time, volunteers on short-termMSTs do not have the opportunity to do so andare therefore more likely to be wasteful in theirpractice.In addition, if volunteers are unfamiliarwith the social and living conditions of ruralNepal, there can be unforeseen consequences ofthe treatments they administer: for example,ibuprofen given to treat stomach ulcers causesinternal bleeding without adequate water or food(Bjarnason et al. 1832); prosthetic hips are life-altering for Nepalese people, who are accustomedto squatting (Dupuis 434); antibiotics can some-times trigger unexpected allergic reactions (Llorand Cots 1349); and anti-diarrhea medicationsare counterproductive when taken with contam-inated water (Werner 22). Moreover, medicinebottles with labels in a foreign language are riskyin the Nepalese culture, which highly encouragessharing (Montgomery 97).A foreign HCP’s lack of awareness of localconditions can, in extreme cases, even lead todeath. Citrin recounts the example of a Nepalesewoman that died after undergoing dewormingsurgery, all because a foreign HCP decided thatthe donated blood did not have to be testedbeforehand (Citrin 55). In this case, the vol-unteer’s unfamiliarity with the region led to anunnecessary death; she failed to recognize thatblood verification is essential in a country withrising rates of HIV/AIDS. In another instance,a local patient received a deadly infection afterbeing operated on in an unsterile room (58).These fatal mistakes were catalyzed by negli-gence and the “better than nothing” mentality,which encouraged volunteers to make decisionswith harmful repercussions.ConclusionsAs explored in this report, short-term MSTsand international volunteering hinder the de-velopment of the Nepalese health care system.They can discourage government investment inthe health sector, worsen job prospects for localhealth workers, and fuel the “medicalization” ofhealth care. Their short duration encourages apaternalistic relationship between the sendingand host countries, ethical double standards,and subpar provision of care. The aid given can,at best, be considered a “band-aid solution” tothe greater, multilayered problems that are af-flicting the overall Nepalese health care system.Normally, the drawbacks of MST operations14
in Nepal could be weighed against the benefitsof getting life-saving medical care to underprivi-leged people that desperately need it. However,the incompetence of the international volunteers,accompanied by a lack of cultural and socialawareness, exposes patients to numerous un-foreseen complications-some of which are fatal.Given the great difficulties that locals endure totravel to the NGO health posts, it is crucial thatMSTs fulfill their promise of healing, rather thanhurting, their patients.If MSTs are not properly fulfilling their maingoal of providing immediate relief to rural folk inNepal, and are hurting long-term development,should we completely avoid them? It is unde-niable that countless people in Nepal rely onforeign medical assistance for survival. StoppingMST operations would endanger these lives, andbring other ethical concerns into question. Atthe same time, continuing MST projects in theircurrent state, while knowing of their potentialharms to the Nepalese health system, is unac-ceptable.Accordingly, future research should considerdeveloping guidelines and “best practices” forNGOs facilitating MSTs in Nepal. To betterinform changes in NGO policy, there is a needfor more empirical research that qualitatively orquantitatively measures the impacts of MSTs.It is therefore vital that NGOs begin to collectdata to transparently monitor their operations.In addition, long-term service trips (lasting forseveral months at a time) should be popular-ized over short-term trips to mitigate the lack ofcultural awareness and accountability. Further-more, MSTs should focus on capacity building byemphasizing knowledge transfer and professionaldevelopment, as opposed to technical and clinicalassistance. These recommended MST structurescan more effectively serve a countrys immediatehealthcare needs, while simultaneously work-ing towards achieving its developmental goals(Schech et al. 362). There may be no “perfectrecipe,” but international medical volunteerismin Nepal must ultimately be reformed so that itbetter helps the people it aims to care for.About the AuthorMy name is Parnika, and I recently completed my first year in the Arts and Science program atMcMaster University. I have an interest in global health and sustainable development. This pieceabout medical service trips in Nepal is a response to the emerging trend of undergraduate students‘voluntouring’ overseas, with the aim of strengthening their applications to medical school. I hopethat this work sheds light on what is an overall complex and multi-layered topic.15
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The Value of Interactional Expertise: Perceptions ofLaypeople, Interactional Experts, and Contributory ExpertsMaytal PerlmanIntroductionIn their bookRethinking Expertise, sociolo-gists Harry Collins and Robert Evans lay out aframework for classifying expertise which theydub “The Periodic Table of Expertise” (Collins& Evans, 2007). They envision the table to takethe form of a ladder, with each rung representinga different level of specialist expertise (Collins& Evans, 2007). Collins and Evans revise pre-existing concepts of this “ladder of expertise” byincluding a rung called “interactional expertise.”Interactional expertise is the second highest rungon the ladder. It is the level immediately below“contributory expertise”, which comprises thehighest level of specialist knowledge and is pop-ulated by PhDs, MDs and the like. Accordingto Collins and Evans, interactional experts areproficient in the language of a specialist domain,but they do not actively practice the science ofthat domain.In this paper I will take a deeper look at howinteractional experts are likely to be perceivedby themselves and by others. In doing so, I willuncover what I believe are shortcomings of the“interactional expertise” label. In particular, Iargue that Collins and Evans do not account forthe limitations of interactional expertise causedby the way contributory experts and laypeople19
perceive the value and credibility of interactionalexperts. In Section 1, I provide an overview ofCollins and Evans’ framework for classifying ex-pertise and outline the definition of interactionalexpertise as conceived by Collins and Evans. InSection 2, I analyze how interactional exper-tise is assessed and by whom. I examine theoperational definition of interactional expertiseemployed by Collins and Evans, as well as amore inclusive operational definition proposedby Kathryn Plaisance and Eric Kennedy. Indoing so, I argue that because laypeople can-not measure interactional expertise, the label islimited in its ability to bridge the gap betweenscience and society. In Section 3, I explore therelationship between contributory experts andinteractional experts, considering the potentialfor tensions to arise due to each party overes-timating the value of their respective expertise.I continue with a discussion on the merits of acontributory expert. Then, in Section 4, I dis-cuss the relative merits of interactional experts,and claim that while contributory experts canalso possess interactional expertise, they cannotprovide the same value as solely interactionalexperts. I argue that the solely interactional ex-pert can have a different approach to a problemwithin a discipline because of their lack of con-tributory expertise in that discipline. I comparethis claim to a similar account of the value ofdiffering perspectives seen in design-thinking. InSection 5, I explore how the unique abilities of aninteractional expert might lead the interactionalexpert to inflate the value of their expertise rel-ative to that of the contributory expert. Finally,I conclude that optimizing how interactional ex-pertise is perceived by laypeople, interactionalexperts, and contributory experts is a criticalstep towards realizing the full benefits of theinteractional expertise concept.Section 1In their book, Collins and Evans introducethe “Periodic Table of Expertise”, a frameworkfor classifying different levels of expertise andknowledge (Collins & Evans, 2007). Accordingto Collins and Evans, there are five levels ofspecialist expertises, and they can be viewed asthe five rungs of a “ladder of specialist exper-tises”. The highest rung on Collins and Evans’“ladder of specialist expertises” is “contributoryexpertise.” Contributory expertise is the kind ofexpertise associated with those practicing sci-ence at its core, such as individuals with PhDsand researchers. Contributory experts have pro-gressed through a five stage model of expertiseacquisition, going from novice to advanced be-ginner, competence, proficiency, and finally toexpertise (Collins & Evans, 2007). As a con-tributory expert, the individual has embodiedthe skills and internalized the content of the sci-ence (Plaisance, 2015). These experts not onlycontribute to the knowledge in their field, butpractice alongside other experts at the core of thediscipline. This “enculturation” is fundamentalfor acquiring the tacit knowledge that must beunderstood as a contributory expert (Collins &Evans, 2007). In their book, Collins and Evansintroduce a new level of expertise, “interactionalexpertise” which lies immediately below con-tributory expertise. Interactional expertise isexpertise in a disciplinary language, without ex-pertise in the corresponding disciplinary practice(Collins & Evans, 2007). The interactional ex-pert can speak the language of a discipline withthe same fluency as the contributory expert, butwithout actually practicing the skills of the dis-cipline. Interactional expertise does not requirethe acquisition of a formal degree. Rather, itis achieved by enculturation in the communityof a discipline, without complete immersion inthe physical aspects of the community (Collins& Evans, 2007).The addition of interactional expertise as alevel of specialist expertise was the product ofa desire to better classify knowledge and exper-tise. The concept of interactional expertise wasborn out of Collins and Evans’ experiences as so-ciologists immersed in other specialist domains(Collins & Evans, 2007). In their work, theynot only collaborate with people of different dis-ciplinary backgrounds, but delve deep into the20
language of a discipline such that, in speech,they are indistinguishable from the experts withwhom they are working (Collins & Evans, 2007).Essentially, Collins and Evans have each ac-quired interactional expertise, and recognized agap in existing expertise classification systems(Collins & Evans, 2007). They identified thatthey possessed a thorough knowledge of a dis-cipline (in addition to the one in which theywere originally trained); which had previouslynot been recognized as significant.In devel-oping a framework for expertise that includedinteractional expertise, Collins and Evans aimedto address the gap they had identified between“primary source knowledge” and “contributoryexpertise” (Collins & Evans, 2007). By creatinga new level of expertise, Collins and Evans shedlight on the importance of interactional exper-tise and its unique properties.Section 2Collins and Evans‘ development of the in-teractional expertise label is most successful inattesting value to the knowledge of individualsthat are fluent in the language of a specialist do-main without practicing the skills of the domain.Likewise, the biggest limitation of the interac-tional expertise label is its lack of far-reachingcredibility. When a hopeful interactional ex-pert is acquiring their expertise, they undergoa progression from “interview” to “discussion”to “conversation” with the contributory expert(Collins & Evans, 2007). They incrementallylearn more and more of the language until thecontributory expert willingly converses with theinteractional expert about the practice of theirscience (Plaisance, 2015), and is even receptiveto critical comments from the interactional ex-pert (Collins & Evans, 2007). When discoursingwith experts who were not involved in help-ing the interactional expert gain their expertise,they must still have their expertise validated bythe individuals or groups with whom they areinteracting. Moreover, while the interactionalexpert may be considered credible within theinner circle of the domain in which they haveinteractional expertise, this does not translateinto credibility amongst laypeople farther downthe ladder.Collins and Evans discuss passing an “imi-tation game” as the marker of a true interac-tional expert (Collins & Evans, 2007). To suc-ceed, an interactional expert must demonstratetheir fluency in the language of a discipline byproficiently answering domain-specific questionsposed by a judge such that the judge identifiesthe individual as a contributory expert. Thismethod for determining interactional expertiseis challenged by Kathryn Plaisance and EricKennedy in their 2014 paper wherein they buildupon Collins and Evans’ framework to develop amore pluralistic account of interactional exper-tise (Plaisance & Kennedy, 2014). The authorscritique Collins and Evans’ adherence to theimitation game as the defining measure of in-teractional expertise. Plaisance and Kennedyposit that in limiting the operational definitionof interactional experts to those that pass theimitation game, Collins and Evans exclude cer-tain individuals or groups that possess relevantinteractional expertise in keeping with the orig-inal operational definition of interactional ex-pertise as having “enough expertise to interactinterestingly with participants and carry out asociological analysis” (Collins & Evans, 2002).Plaisance and Kennedy therefore argue for apluralistic account of interactional expertise, op-erationally defined by the interactional expert’sability to interact interestingly with contribu-tory experts (Plaisance & Kennedy, 2014).Both operational definitions, however, re-quire the evaluator to have contributory exper-tise. The judge in the imitation game and theperson who identifies instances of “interact[ing]interestingly” must have contributory expertisein the domain of interest in order to do so. Thisruns counter to one of the primary objectivesof interactional expertise, namely, to increasethe uptake of scientific knowledge and mediatebetween scientific communities and importantstakeholders (Plaisance & Kennedy, 2014). Ifthe concept of interactional expertise is to re-21
alize its full potential, then individuals withless expertise than an interactional expert (andtherefore contributory expert) must be able toassess the credibility of an interactional expert.As it stands, interactional experts may betrusted by laypeople based on their affiliationwith contributory experts. If the interactionalexpert’s credibility is contingent on their associ-ation with contributory experts, this can add anadditional layer of complexity to the relationshipbetween interactional expert and contributoryexpert.Section 3In their book, Collins and Evans discuss howthe different specialist expertises relate to oneanother in terms of their transitivity: on the“ladder of specialist expertises”, those at higherrungs inherently have the expertise of all therungs below them as well (Collins & Evans,2007). While they establish the transitivity ofthe levels of expertise, they do not touch on therelationship between experts at different levels.Most lacking is a discussion of the relationshipbetween interactional experts and contributoryexperts. Such a discussion is crucial because theidentity of an interactional expert (and thereforethe definition of interactional expertise) hingeson that of the contributory expert. Thus, theinner workings of this relationship are of ut-most importance as they in turn reveal both thetriumphs and shortcomings of the interactionalexpertise label.The relationship between a contributory ex-pert and an interactional expert within a domainhas the opportunity to be, and often is, mutuallybeneficial. However, tensions may arise betweenthe two as a result of inflated valuations of ex-pertise. As mentioned earlier, the contributoryexpert has traditional formal, training such asa doctorate, and has spent years moving up theacademic ranks to achieve this accreditation.Alternatively, the interactional expert has infor-mal experience in the specialist domain. Giventhe contributory expert’s formal expertise in thedomain of interest, they might value their ownform of expertise more highly than that of theinteractional expert. This may be further ex-acerbated in the case of an interactional expertthat is not also a contributory expert in an-other specialist domain. Interactional experts inthis category may already be from marginalizedgroups, and therefore may have their relevant ex-pertise further under-valued by the contributoryexpert (Plaisance & Kennedy, 2014). However,to a certain extent, the contributory expert’svaluation may be reasonable, and it is impor-tant to remember that “it is the contributoryexperts not the interactional experts who defineand develop the content of the language thatthe interactional expert tries to master” (Collins& Evans, 2007). The contributory experts arethe ones actuallydoingthe science, and whileinteractional experts cantalkabout the science,they cannot practice it (Collins & Evans, 2007).Section 4In establishing the interactional expertise la-bel, Collins and Evans recognize the value ofinteractional experts and their role as special-ists in a discipline. By definition, interactionalexperts cannot perform the work of contribu-tory experts, but it is equally important to notethat many contributory experts are not doingthe work of interactional experts. The contri-bution of interactional experts is made possi-ble by their inherent interactive and reflectiveabilities, skills which are not always shared bycontributory experts (Collins & Evans, 2007).According to Collins and Evans, “interactiveabilities” are interpersonal skills that enable anindividual to communicate and interact withothers. Alternatively, “reflective abilities” arethe contemplative, critical thinking skills thatare vital for an interactional expert’s analy-sis.The importance of these abilities withregards to the efficacy of the interactional ex-pert can be understood through Collins andEvans’ analogy of the interactional expert asa coach. When instructing the player how toperform an action, the coach/interactional ex-pert must have strong interactive abilities if they22
are to effectively communicate tacit knowledgeto the player/contributory expert (Collins &Evans, 2007). Interactive ability is the mech-anism by which interactional experts articulatetacit knowledge to the contributory expert. Thistask lies solely in the hands of the interactionalexpert, who has all the tacit knowledge of thecontributory expert, but can still access the rulesand facts that are inaccessible to the contribu-tory expert, in the same way that an experi-enced driver often cannot recall how they droveto work.Another advantage of the interactional ex-pert is that they have a different perspective tothink critically about the problems facing thedomain of interest. Collins and Evans state thatone of the basic principles of their table is thatindividuals possessing higher levels of expertisealso possess the expertise of all the precedinglevels (Collins & Evans, 2007). Therefore, con-tributory experts must also possess interactionalexpertise, though their interactional expertisecan be either latent or realized (Collins & Evans,2007). According to Collins and Evans, a solelyinteractional expert in a field can add the samevalue as a contributory expert in that field whoalso has realized interactional expertise (Collins& Evans, 2007). While both individuals maybe considered to possess interactional expertisein that field, I disagree that they can add thesame value as interactional experts. Someonewith only interactional expertise in a specificfield has a distinct epistemic perspective fromsomeone with both contributory expertise andrealized interactional expertise in the same field.While they are both fluent in the language ofthe discipline, they may speak different dialectsthat signify where they were “raised”, and wherethey learned the language. The solely interac-tional expert did not receive the same trainingas the contributory and interactional expert.They were not taught the same ideologies, andwere not “raised” with the same disciplinarynorms passed down to the contributory-and-interactional expert via formal education. Forthis reason, the solely interactional expert canhave a different approach to a problem within adiscipline resulting from their lack of contribu-tory expertise in that discipline.The added value of differing perspectives isencountered in design-thinking as well. In hisbookGlimmer, Warren Berger collaborates withtop designer Bruce Mau to share how designcan improve our lives and transform the world(Berger, 2009). According to Berger, the act ofquestioning basic assumptions can lead to trueinnovation.Along with questioning assump-tions, reframing familiar problems in unconven-tional ways can lead to meaningful solutions(Berger, 2009). These two design principles relyon the relative “ignorance” of the designer com-pared to the client. Without the depth of tacitknowledge tying them down, the designer is ableto look at a problem without subconscious as-sumptions getting in the way of a solution. PaulaScher is quoted inGlimmeras saying that “ifyoure trying to find a new way to think aboutsomething that makes it better, it can actuallyhurt you to have too much experience in that mi-lieu - because you understand the expectationstoo well. And that can cause you to edit yourpossibilities based on what you already know‘doesn’t work’” (Berger, 2009). In the case ofexpertise, it is because the interactional expertisn’tdoingthe science that they are in a positionto challengewhythe contributory expert is doingsomething in a certain way, and may then be ableto use their objectivity to find a better way todo said task. One may be inclined to object theapplication of this principle to interactional ex-perts, because by definition interactional expertsare just as fluent in the language of a disciplineas the contributory experts are, and thereforetheydoknow the background knowledge. Whilethey do have more disciplinary knowledge thanthe designers Berger describes, they have no ex-perience actually performing the actions of thatdiscipline, thereby making this principle appli-cable.Section 5In discussing the relative merits of interac-23
tional and contributory expertise, it is worthexploring potential complexities that arise inthe relationship between interactional and con-tributory experts as a result of each expert’sperception of the other and valuation of theother’s expertise. The contributory expert, inkeeping with Collins and Evans illustration of a“ladder of expertises”, can easily view their ex-pertise as more valuable than that of individualslower down the ladder, specifically interactionalexperts. The concept of interactional expertise isdefined by the interactional expert’s inability todo something that the contributory expert can:practice the science of the specialist domain.However, after proposing that the interactionalexpert is able to add value in a way that thecontributory expert cannot, I now explore thepotential implications of this re-weighted inter-actional/contributory expert relationship.Indoing so, I do not intend to assign static valuejudgements to interactional or contributory ex-pertise. Rather, I examine the range of waysin which interactional and contributory expertsperceive each other’s expertise.In doing so,I identify opportunities to further develop theconcept of interactional expertise in a way thataddresses and responds to possible tensions be-tween the two groups.As previously noted, the contributory expertmay over-estimate the value of their expertisebased on their formal training and experiencepracticing the science of the domain. Likewise,the merits of possessing only interactional exper-tise may cause the interactional expert to inflatethe value of their expertise relative to that ofthe contributory expert. This idea is supportedby the findings of a 2007 study on the identi-ties of creative workers in advertising agencies(Hackley & Kover, 2007). Authors Chris Hack-ley and Arthur Kover interviewed copywritersfrom several advertising agencies in New Yorkand described how several interviewees “iden-tified themselves as members of an elite whoserole it is to use their fine judgment as creativeindividuals to inspire consumers” (Hackley &Kover, 2007). Hackley and Kover note that cre-atives assume they understand advertising betterthan the account managers, even though thosein other departments may undermine the pro-fessional legitimacy of creative work (Hackley &Kover, 2007). In the same way that the uniqueskillset of creative workers in advertising hasled to elitism amongst certain creative workers,there is a risk of interactional experts developingsimilar attitudes. Although, this may not be amajor cause of concern because the merits of in-teractional expertise and other integrative skillsare less frequently recognized compared to thoseof highly specialized expertise. However, if a con-tributory expert’s inflated valuation of their ownexpertise can be traced back to their disciplinarytraining, then we must also be cautious not tonurture a similar sentiment in interdisciplinarytraining that heavily values interactional exper-tise. The inflated valuations of expertise of bothinteractional experts and contributory expertscan threaten the interactional/contributory ex-pert relationship, and in turn the success of theconcept of interactional expertise as a whole.ConclusionThe concept of interactional expertise is in-strumental in legitimizing the expertise thatindividuals acquire as a result of enculturationin a specialist domain without practicing the sci-ence of that domain. Interactional experts areuniquely positioned to bridge gaps between sci-ence and society; however, this ability is limitedby the inability of laypeople to identify interac-tional expertise. Laypeople cannot serve as thejudge in Collins and Evans’ imitation game, norcan they necessarily determine whether an indi-vidual has “interact[ed] interestingly” with con-tributory experts. Thus, laypeople may perceivea subject’s interactional expertise only throughtheir association with contributory experts. Thisdependence on contributory experts for deter-mining interactional expertise has the potentialto complicate the relationship between the twotypes of experts. This relationship is already lay-ered and complex due to the ways contributoryexperts and interactional experts each determine24
the value of their own expertise. Contributoryexperts, as the highest ranking experts, mayinflate the value of their expertise relative to in-teractional experts, who do not have traditional,recognized accreditation nor do they actuallypractice the science of the discipline. However,interactional experts add value in other ways,including by providing different perspectives notinfluenced by experiencedoingthe science. Assuch, there is also the potential for interactionalexperts to inflate the value of their expertise rel-ative to that of contributory experts. While notnecessarily realized in all contexts, these possi-bilities are important to consider as the conceptof interactional expertise continues to develop,especially because the success of interactionalexpertise is closely connected to the success ofthe relationship between interactional and con-tributory experts. Moving forward, Collins andEvans’ framework can be improved upon byfurther addressing the nuances of the interac-tional expert and contributory expert relation-ship.Moreover, improving how interactionalexpertise is perceived by laypeople, interactionalexperts, and contributory experts is a criticalstep towards realizing the full benefits of theinteractional expertise concept.About the AuthorMaytal Perlman is a student in the Knowledge Integration program at the University of Waterloo.Her academic interests include philosophy of science, health sciences, collaborative design, anddrama & speech communication. Maytal is interested in exploring how design and collaborationpractices can be used to improve patient care and healthcare outcomes. She began working onthis piece as a student in Dr. Kathryn Plaisance’s class “The Nature of Scientific Knowledge”.Maytal’s discussion on the concept of interactional expertise and how its value is perceived byvarious stakeholders is applicable to any specialist domain, and was inspired by her own experiencesreceiving an interdisciplinary education. She was motivated to publish in this journal because JIRRprovides a space to engage in academic conversation that is not only interdisciplinary in nature,but directly concerns the study and practice of interdisciplinarity.25
ReferencesBerger, W. (2009).Glimmer: How Design Can Transform the World. Toronto: Random HouseCanada.Collins, H., & Evans, R. (2002). The third wave of science studies: Studies of expertise and experi-ence.Social Studies of Science, 32(2), 235-296. https://doi.org/10.1177/0306312702032002003.Collins, H., & Evans, R. (2007).Rethinking Expertise. Chicago: The University of Chicago Press.Hackley, C., & Kover, A. J. (2007). The trouble with creatives: negotiating creative identity in ad-vertising agencies.International Journal of Advertising, 26(1), 63-78. https://doi.org/10.1080/02650487.2007.11072996.Plaisance, K. (2015, November 17). Expertise Across Disciplines: Interactional Expertise. Water-loo, Ontario.Plaisance, K. S., & Kennedy, E. B. (2014). A pluralistic approach to interactional expertise.Studiesin History and Philosophy of Science, 47, 60-68. http://dx.doi.org/10.1016/j.shpsa.2014.07.001.26
The Deterrent Effects of Corporate Punishment: Restoringthe Broken Image of the Pharmaceutical IndustryEmily WongIntroductionOver three hundred million people live inthe United States, home of the world’s largesthealthcare industry. In the United States,$300billion a year is spent on prescription drugsalone, and that number is rising. Despite theundisputed fact that pharmaceutical companieshave made significant contributions to healthcare and in improving quality of life for patients,they are regularly critiqued as one of the leasttrusted industries, next to the nuclear industry,in public opinion surveys.2Numerous pharma-ceutical companies commit crimes severe enoughto be ranked in the top 100 corporate criminalslist.3However, when it comes time to prosecutethem, their punishments are a mild reprimandfor their crimes. Medications, and the industrythat governs their development, the pharma-ceutical industry, are human creations made toimprove and extend our natural health bound-aries and quality of life. However, what happenswhen too much power is extended to a technolog-2David Taylor, “The Pharmaceutical Industry and the Future of Drug Development”, Pharmaceuticals in theEnvironment, 2015, 1-33.3Mokhiber, Russell, and Robert Weissman. “Top 100 Corporate Criminals of the 1990s.” Mother Jones,Mother Jones, 28 June 2017, www.motherjones.com/politics/1999/09/top-100-corporate-criminals-1990s/.27
ical system* that holds control of our most basicand vital human rights, namely that of healthand life? Pharmaceutical companies are oftendeemed as the “thugs” of the medical industrybecause, like giant banks on Wall Street, theyare accepted as too big to fail.4Like many phar-maceutical companies, Pfizer abuses the powergranted by the structure of the healthcare sys-tem to illegally commercialize products at theexpense of a patient’s wellbeing without takingfull responsibility of their actions when caught.This injustice causes societal implications, andall participants that ought to be “winners” ben-efitting from this technological system (e.g. pa-tients, doctors, pharmaceutical companies, andthe healthcare industry) instead secure morelosses, ultimately becoming “losers” of the sys-tem. However, solutions in restoring the imageof the pharmaceutical industry can generate thenecessary stubborn change.This Investigation seeks to explore the neg-ative societal implications of limited regulationin unethical criminal acts of pharmaceutical gi-ants and potential solutions to increase publictrust in Big Pharma. It does this by drawingon literature from medical history, philosophy,and sociology. This piece integrates ideas fromthese disciplines by utilizing the ideas of an ex-perienced physician and health journalist, anemeritus sociology professor interested in socio-technological systems, and an interdisciplinaryHarvard philosophy and technology studies pro-fessor to better understand the ramificationsof America’s self-destructive health care systemand generate potential solutions to remedy itsgrave impacts on society.*Note: the term technological system is usedthroughout this piece because medication anddrugs are considered to be pieces of technologywith the practical purpose of treatment, care,and promotion of health. The pharmaceuticalindustry is a system that employs drugs andmedications, as is in large part a participant ofthe health care system.BackgroundPfizer researches, develops, and producesvaccines and medications over a range of medi-cal disciplines, including the widely known littleblue pill, Viagra. The global pharmaceutical gi-ant was established and produced its first prod-uct in 18495and has since accumulated over$4billion in fines.6Pfizer’s fourth settlement overillegal marketing activities was the largest por-tion of the$4 billion. An historic$2.3 billionsettlement resolved the civil and criminal alle-gations in fraudulent marking for the painkillerBextra, and other drugs including the antipsy-chotic Geodon, the antibiotic Zyvox, and theantiepileptic Lyrica.7As of 2009, this settle-ment was the largest criminal charge of any kindimposed in the United States.8Bextra was identified as part of a radicalclass of painkillers known as cyclooxygenase 2(COX-2) inhibitors, at twenty times the price ofibuprofen, but intended to be safer than genericdrugs.9In 2001, Bextra was proposed to hitthe market as an acute pain treatment aftersurgery.The U.S. Food and Drug Adminis-tration (FDA) approved Bextra for menstrualcramps and arthritis but deemed it unsafe athigher doses for acute surgical pain and for pa-4Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.5Pfizer Inc., “Pfizer Company History”, http://www.pfizer.com/about/history/all6Pfizer Inc. and Subsidiary Companies, “Pfizer 2010 Financial Report”, 2010, 66-68,http://www.pfizer.com/files/annualreport/2010/financial/financial2010.pdf.7Office of Public Affairs, “Justice Department Announces Largest Health care fraud Settlement in Its History”,The United States Department of Justice, September 2, 2009, https://www.justice.gov/opa/pr/justice-department-announces-largest-health-care-fraud-settlement-its-history.8“The Case Against Pfizer”, The Federal Bureau of Investigation, September 2, 2009,https://archives.fbi.gov/archives/news/stories/2009/september/pfizersettlement090209.9Mark Ratner, “Pfizer settles largest ever fraud suit for off-label promotion”, Nature Biotechnology 27 (2009):961-962.28
tients at high risk of heart attacks. With bil-lions in profit at stake, Pfizer and its partner,Pharmacia, neglected the approval of the FDAand employed teams of sale managers across thecountry to market Bextra to health care pro-fessionals.10To further incentivize prescriptionorders from doctors, a multimillion dollar budgetintended for medical education was used insteadto illegally pay doctors as promotional speakersand consultants for Bextra and other drugs.The act of promoting drugs for unapproveduses is called “off-label marketing” and it isjudged as a criminal offence because it canseverely harm the lives of patients, especiallythose with dire health conditions.11Even know-ingly so, CNN Special Investigations Unit re-ported that a scripted sales pitch from Pfizerwas emailed to sales representatives in Floridawhich condoned sales up to a 40 mg dose, twicewhat the FDA deemed to be safe.12In court,Pfizer pleaded that, “the company’s intent waspure”.13However, when Bextra was taken offthe market in April 2005, “more than half of its$1.7 billion in profits had come from prescrip-tions written for uses the FDA had rejected.”14Consequently, while the intent behind produc-ing Bextra was to provide another alternativeto improve the lives of patients suffering frompain, marketing Bextra at harmful unapproveddosages only harms these patients If more thanhalf of the earnings from Bextra came from off-label marketing, it is hard to believe Pfizer pro-moted Bextra with the patient’s best interest inmind.The Conviction and SettlementThe number of patient lives put at risk in-creased with every sale of Bextra. Consideringthis was Pfizer’s fourth settlement over fraudu-lent marketing, the punishments for their crimesshould logically increase in severity to cripplethe company enough such that they learn theirlesson.However, with the following compli-cated legalities of the case, Pfizer escaped severecorporate punishment and even had difficultiesbearing the requirements of their favorable reso-lution.Any company convicted of serious health carefraud faces automatic exclusion from Medicareand Medicaid as the one of harshest forms ofcorporate punishment. Doing so will prevent acompany from collecting compensation for theproducts it provides to Medicare and Medicaid.Prosecutors tried convicting Pfizer with the au-tomatic exclusion clause that would lead toPfizer’s collapse. However, Pfizer’s general coun-sel, Amy Schulman, urged: “the vast majorityof our employees spend their lives dedicated tobringing truly important medications to patientsand physicians in an appropriate manner.”15Therefore, in consideration of the Pfizer employ-ees not involved in fraudulent activity, patientsrelying on Pfizer products through Medicare andMedicaid, and the losses for Pfizer shareholders,Pfizer was given an exception from the auto-matic exclusion condition.16For redemption forall prior cases of fraudulent marketing, Pfizerwas given a fourth chance.Instead of imparting a criminal charge uponPfizer, prosecutors agreed to charge Pfizer10Mark Ratner, “Pfizer settles largest ever fraud suit for off-label promotion”, Nature Biotechnology 27 (2009):961-962.11Erin Janssen, “Pfizer Settlement Makes History”, Journal of Health Care Compliance, December 2009, 33-36.12Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.13Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.14Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.15Gardiner Harris, “Pfizer Pays$2.3 Billion to Settle Marketing Case”, The New York Times, September 2,2009, http://www.nytimes.com/2009/09/03/business/03health.html.16Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.29
through its subsidiary, Pharmacia & Upjohn Co.Inc. A subsidiary corporation is defined as one inwhich a generally larger company, known as theparent corporation owns all or most of its shares.As the owner of the subsidiary, the parent cor-poration controls the activities of the subsidiary.Instead of a merger, forming a subsidiary maybe more beneficial to the parent company be-cause the approval of the stockholders is notrequired and the parent owns a controlling in-terest with a smaller investment. The parentand subsidiary remains as separate legal entitiesand the subsidiary may produce goods and ser-vices completely different from those producedby the parent company.17Pfizer owns Pharma-cia & Upjohn Co. Inc. through inheritance inowning Pharmacia & Upjohn LLC which ownsPharmacia & Upjohn CO. LLC which then ownsPharmacia & Upjohn Co. Inc. If Pfizer was theparent, the company charged with the subsidiaryis the greatgreat-grandson.18Pharmacia & Up-john Co. Inc. was incorporated on March 27,2007 in Delaware. This was the same day whenfederal prosecutors and Pfizer lawyers battledit out, which led to Pfizer pleading guilty for abribery case a few years prior to the Bextra case.Thus, Pharmacia & Upjohn Co. Inc., the pro-tective bodyguard against criminal charges forPfizer was born. The bribery case ended withPharmacia & Upjohn Co Inc. pleading guiltyfor Pfizer, and Pharmacia was excluded fromMedicare while Pfizer was free to commercializethrough federally funded health programs. Thesame pattern was observed in the Bextra case.Pharmacia pleaded guilty without ever havingsold a single pill or dosage of Bextra, while Pfizerwas still permitted to sell its products to feder-ally funded health programs. The subsidiary wasnothing more than a shell company protectingPfizer when it got caught in hot waters.19SincePharmacia’s sole function was to take criminalpleas for Pfizer, the impact of corporate punish-ment was severely minimized.Pfizer paid almost$1.2 billion for Bextra butPharmacia & Upjohn Co. Inc. was responsiblefor the rest.20Together, the fees total to$2.3billion, a record fine for any crime.21Precedingthe Bextra case,$1.2 billion was the largest sumthe federal government has ever collected, untiltogether, Pharmacia and Pfizer nearly doubledit. However, to put the money into perspective,even the total$2.3 billion collected amountsto less than three weeks of sales at Pfizer.22Therefore, although$2.3 billion seems like dev-astating debt to pay, for a pharmaceutical gi-ant like Pfizer, it may simply be spare pocketchange. Harvard Medical School health scienceresearcher and attorney, Aaron Kesselheim, wor-ries that “settlements for fraud should do morethan punish a particular company. . . it shouldsend a message to the industry about whatare-or are not-reasonable practices. . . there’s abig question as to whether these settlementsactually do that.”23Corporate punishment ismeant to serve as a deterrent against criminalmisconduct, but the punishment for Pfizer wasessentially halved because they did not take fullresponsibility for their crime. Instead, Pfizercreated an imaginary friend to take the fall forthem.17“Subsidiary.” The Free Dictionary, Farlex, legal-dictionary.thefreedictionary.com/subsidiary.18Drew Griffin and Andy Segal, “Feds Found Pfizer too big to nail”, CNN Health, April 2, 2010,http://www.cnn.com/2010/HEALTH/04/02/pfizer.bextra/.19David Tippie, “Collapse of Drugs Due to Wellness” (Lulu Com, 2010), 1220Office of Public Affairs, “Justice Department Announces Largest Health care fraud Settlement in Its History”,The United States Department of Justice, September 2, 2009, https://www.justice.gov/opa/pr/justice-department-announces-largest-health-care-fraud-settlement-its-history.21“The Case Against Pfizer”, The Federal Bureau of Investigation, September 2, 2009,https://archives.fbi.gov/archives/news/stories/2009/september/pfizersettlement090209.22Gardiner Harris, “Pfizer Pays$2.3 Billion to Settle Marketing Case”, The New York Times, September 2,2009, http://www.nytimes.com/2009/09/03/business/03health.html.23Mark Ratner, “Pfizer settles largest ever fraud suit for off-label promotion”, Nature Biotechnology 27 (2009):961-962.30