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Editorial Staff Advisory Board Editor in Chief Faculty/Staff Advisor Reagan Fitzke Mary Swanson Colorado State University Office for Scholarship and Fellowship Advising Managing Editor Zachary Shepard Faculty Advisory Board Dr. Susan Athey Business Associate Editors/Copy Editors Dr. Mark Brown Linda Fischbacher Veterinary Medicine and Biomedical Sciences Cheyanne Izon Dr. Stephan Weiler Brynn Moore Liberal Arts Raegan Petch Dr. Chris Myrick Matthew Yohannes Natural Resources Tiger Zhang Dr. Matt Hickey Health and Human Sciences Dr. Nancy Irlbeck Affiliate Editors Agricultural Sciences Saad Bhatti Dr. Don Mykles Sabreen Miah Natural Sciences Monica Zhang Dr. Tom Siller Engineering

Journal of Undergraduate Research – Volume X iii A Letter from the Editor in Chief

JUR Press is proud to present Volume X of the Journal of Undergraduate Research, our tenth anniversary edition, with published works across a wide range of disciplines by undergraduates from around the world. We are a journal for undergraduates and by undergraduates. Our slogan –­ linking the global undergraduate community –­ captures our mission to serve the interests of worldwide undergraduate thinkers, tinkerers, experimenters, writers, and artists. While JUR does provide a platform for students to publish and showcase their work, we also give students the opportunity to learn about the publication process from start to finish through internships as editors, operations associates, and reviewers. Our undergraduate network has grown to include not only international authors, but also affiliate and satellite editors from around the world! We are truly committed to enhancing the undergraduate experience, and we continually seek to engage as many undergraduate students in our organization as possible. I am so incredibly thankful to have had the opportunity to serve as Editor-in-Chief for the Journal of Undergraduate Research, and to work alongside a cohort of brilliant editors, authors, and mentors to put together work that honors the experience of novel and innovative ideologies in undergraduate careers. The hard work the staff and authors have poured into this has been truly inspiring. It is essential for this generation to continue to question, learn, and critically think about real-world problems. I am so proud of everyone who has been involved in this process and hope that it is a cause for great celebration to publish works that may have a great impact. I sincerely hope that this work can continue into every individual's graduate and professional careers. Your contributions are significant and will continue to be for much time to come.

I truly hope this journal can continue to empower and embolden the voices of undergraduate scholars long after my tenure is over. It has been inspiring and humbling to commit to this work. I hope to take part of this with me as I continue into my own field of research. Congratulations to all. Warm regards,

Reagan E Fitzke Editor in Chief Journal of Undergraduate Research JUR-Press

iv Journal of Undergraduate Research – Volume X Table of Contents

Title Authors Page

Last Light; Perfect Symmetry; Before Sunrise; Serenity Bryan Bennis, Colorado State University 1

The Importance of Student Engagement and Experiential Learning Mark A. Brown, Ph.D, and Reagan E. Fitzke, Colorado 2 in Undergraduate Education (Staff Editorial) State University

“Small Fishes in a Big Pond?”: An Exploration on the Current Role Laura Minelli, Lancaster University 3 of the Community Pharmacist and Local Pharmaceutical Services in England

Working Towards a Model of Genetic Profiling for Vulnerability/ Saniya Wadhwa1,3, Michelle Chen1,3, Audrey Nikolich2,3, 14 Resiliency to Sleep Loss through a Summer Research Fellowship in Ruthie Ratcliffe, MS3, and Allison Brager, PhD3, a Military Science Laboratory 1University of Maryland College Park, 2Gettysburg College, 3Walter Reed Army Institute of Research

A Review of Treatments of Substance Use Disorder for Transitional Kai Trepka, Fatima Fairfax, Jeffrey He, Eun Jae Kim, 17 Age Adults Mingu Kim, Jeongmin Lee, Rajdeep Trilokekar, and Katherine Venturo-Conerly, Harvard University

Understanding Benthic Macroinvertebrate Communities in Beaver Valerie T. Doebley, Colorado State University 23 Meadows of Rocky Mountain National Park

Canon and Blues: Diverse Influences on Philip Larkin’s “Aubade” Brandon Pahl, University of Iowa 33

J.R.R. Tolkien and Environmental Concerns in Mid-20th Century Drew Heiderscheidt, University of Northern Colorado 36 England

“In the Public Interest”: The Historiography of Crusade Finance Lee Morrison, Florida State University 40

Journal of Undergraduate Research – Volume X v Art Artwork by Bryan Bennis Colorado State University Before Sunrise

Last Light

Perfect Symmetry

Serenity

1 Journal of Undergraduate Research – Volume X Staff Editorial The Importance of Student Engagement and Experiential Learning in Undergraduate Education By Mark A. Brown1,2,3,4,5* and Reagan E. Fitzke6 Colorado State University 1Department of Clinical Sciences, Colorado State University, 80523 2Institute for Learning and Teaching, Colorado State University, 80523 3Department of Ethnic Studies, Colorado State University, 80523 4Epidemiology Section, Colorado School of Public Health, 80523 5Cell and Molecular Biology Program, Colorado State University, 80523 6Department of Psychology, Colorado State University, 80523 *Correspondence: [email protected]; Tel.: (970) 491-5782 Abstract Student engagement is among the essential elements in retention programs for undergraduate students1-6. Studies illustrate that if students do not perceive a sense of belonging, they are at greater risk of departing their institution prior to completing their degree programs. Recognized as a high impact practice, undergraduate research and other forms of experiential learning have been proven to impart the greatest impacts toward the promotion of student engagement7,8. Herein we underscore the importance of student engagement and experiential learning in undergraduate education.

Introduction and other forms of student engagement are 12Strayhorn, T. (2008). “Fittin’ in: Do diverse Student engagement1-6 and a sense of now recognized as essential elements of all interactions with peers affect sense of belonging for 9-14 black men at predominantly white institutions?” Journal belonging have been well documented as undergraduate education. In the past decade of Student Affairs Research and Practice. 45.4. Pg 953– critical contributors toward successful student experiential learning has been integrated 979. retention programs. Higher education across the breadth of academic disciplines, 13Tovar, E. (2013). A conceptual model on the impact of mattering, sense of belonging, engagement/involvement research indicates that when students do not and the early results are just the tip of the and socio-academic integrative experiences on community perceive a sense of belonging or feel engaged, iceberg. college intent to persist. Ph.D. Dissertation. Claremont there is a significantly lower rate of retention. References Graduate University, Claremont, CA. Experiential learning opportunities, such 1Tinto, V. (2017) “Through the eyes of students.” 14Sidanius, J., Laar, C., Levin, S., & Sinclair, S. Journal of College Student Retention: Research, Theory & (2004). “Ethnic enclaves and the dynamics of social as mentored inquiry, are recognized among Practice. 19.3. Pg 254-269. identity on the college campus: The good, the bad, and the high impact practices with the greatest 2Trolian, T., Jach, E., Hanson, J., & Pascarella, E. the ugly.” Journal of Personality and Social Psychology. efficacy among types of programs that seek (2016). “Influencing academic motivation: The effects 87.1. Pg 96–110. to engage undergraduates7,8. From improving of student-faculty interaction.” Journal of College Student 15Chemers, M., Hu, L., & Garcia, B. (2001). 15-20 Development. 57.7. Pg 810–826. “Academic self-efficacy and first-year college student self-efficacy to students’ sense of 3 9-14 Komarraju, M., Musulkin, S., & Bhattacharya, performance and adjustment.” Journal of Educational belonging , experiential learning has been G. (2010). “Role of student faculty interactions in Psychology. 93.1. Pg 55–64. repeatedly proven among positive predictors developing college students’ academic self-concept, 16Bong, M. (2001). “Role of self-efficacy and task- of academic success, retention, and career motivation, and achievement.” Journal of College Student value in predicting college students’ course performance Development. 51.3. Pg 332–342. and future enrollment intentions.” Contemporary success/satisfaction. 4Tinto, V. (2012) Completing college: Rethinking Educational Psychology. 26.4. Pg 553–570. Discussion institutional action. Chicago: The University of Chicago 17Schunk, D. (1995). “Self-efficacy, motivation, Experiential learning supports the Press. and performance.” Journal of Applied Sport Psychology. development of practical problem-solving 5Upcraft, M., Gardner, J. & Barefoot, D. (Eds.). 7.2. Pg 112–137. 21-23 (2005). Challenge and support: Creating climates for first 18Yuong, M., Brown-Welty, S., & Tracz, S. (2010). skills . The application of theory, from year student success. San Francisco: Jossey-Bass. “The effects of self-efficacy on academic success of first- the classroom, afforded by mentored 6Pascarella, E., Seifert, T., and Whitt, E. (2008). generation college sophomore students.” Journal of inquiry improves academic performance and Effective instruction and college student persistence: College Student Development. 51.1. Pg 50–64. students’ ability to define career goals21. With Some new evidence. In The Role of the Classroom 19Hall, J. M., & Ponton, M. K. (2005). in College Student Persistence. Braxton, J., ed. San “Mathematics self-efficacy on college freshmen.”Journal experiential learning, undergraduates’ regular Francisco: Jossey-Bass. of Developmental Education. 28.3. Pg 26–33. interface and solutions to real-world issues, 7Kuh, G. (2018). What Really Makes a ‘High- 20Gore, P. Jr. (2006). “Academic self-efficacy as a followed by contemplation and deliberation Impact' Practice High Impact? Inside Higher Education. predictor of college outcomes: Two incremental validity related to the results of their decisions, May 1, 2018. studies.” Journal of Career Assessment. 14.1. Pg 92–111. 8Kuh, G. (2008, 2011). Student Success in College: 21Boyd, MK and Wesemann, JL. (2009). facilitate the growth and development of The Promise of High Impact Practices.Association of Broadening Participation in Undergraduate Research: their understanding associated with their American Colleges and Universities. Fostering Excellence and Enhancing the Impact. disciplines9. Experiential learning is especially 9Kuh, G., Kinzie, J., Schuh, J., & Whitt, E. Washington, DC: Council on Undergraduate Research. appropriate for connecting complex issues (2005). Student Success in college: Creating Conditions 22Kardash, C.M. (2000). “Evaluation of an 9,10 that matter. San Francisco: Jossey-Bass. undergraduate research experience: Perceptions across disciplines . The significance of 10Bergen, J., & Milem, J. (1999). “The role of ofundergraduate interns and their faculty mentors.” student interactions with faculty mentors as student involvement and perceptions of integration in a Journal of Educational Psychology. 92.1. Pg 191-201. a method of nurturing student engagement causal model of student persistence.” Research in Higher 23National Research Council. Committee on Education. 40.6. Pg 641–664. developments in the Science of Learning and Committee through mentored inquiry is being 11 highlighted among best practices for student Stebleton, M., Soria, K., Huesman, R. Jr., & on Learning Research and Educational Practice. (2000). 1-6 Torres, V. (2014). “Recent immigrant students at How People Learn: Brain, Mind, Experience, and School engagement and retention initiatives . Once research universities: The relationship between campus (expanded ed.) Washington, D.C.: National Academy restricted primarily to STEM and a subset of climate and sense of belonging.” Journal of College Press. social science disciplines, experiential learning Student Development. 55.2. Pg 196–202.

Journal of Undergraduate Research – Volume X 2 “Small Fishes in a Big Pond?”: An Exploration on the Current Role of the Community Pharmacist and Local Pharmaceutical Services in England By Laura Minelli Lancaster University 1. Introduction clinical commissioning groups (CCGs). delivering clinical services and the integration A noticeable discrepancy exists between They are provided in response to local with the General Practitioner? National Health Service England’s (NHSE’s) needs, such as the anticoagulation servicea. 2. In what form is innovation present in plans for preventive care involving community Community pharmacies represent the most Local Pharmaceutical Services (LPSs)? pharmacy and the public perception accessible point of care, with their presence 3. How do Local Pharmaceutical of community pharmacy and the local offering support to the NHS to fight health Services (LPSs) support the fight against pharmaceutical services (LPSs) it provides. inequalities. health inequalities? This divergence was noticed by the researcher National Health Service England has during her work experience in an English recognised the positive effect of allowing In investigating these questions, this pharmaceutical company implementing community pharmacies to provide the above- study reveals the currently missing integration LPS in community pharmacies. The mentioned services, and it has developed between healthcare providers, despite NHSE’s research aims to investigate initially the the pharmacy contractual framework for objectives reported in the “Five-Year Forward current role of community pharmacists community pharmacies. The Community View” (5YFV)7, in implementing integration (CPs) in relation to NHSE’s proposed pharmacists and their teams provide essential, and ensuring efficient use of the CP in integration with general practitioners independent checks and balances within delivering preventive services. It has been (GPs). Tuten and Urban’s1 framework in the medicines supply chain, intervening discovered that competition in delivering business-to-business (B2B) integration has to correct prescribing errors and deal with clinical service is one of the reasons for the been utilised to compare the relationship other issues that could otherwise put patient lack of a strong relationship between CPs between CPs and GPs and to understand safety or outcomes at risk. They also use and GPs. The concept of innovation in LPS how healthcare professionals’ relationships their expertise in medicines procurement turned out to be linked to the accessibility differ from business cooperation. Moreover, to deliver purchasing efficiency, helping the of new services by the population rather the researcher decided to explore the topic NHS manage the total cost of medicines5. than the introduction of a completely new of innovation in LPS. The framework The community pharmacy is a major setting service derived by technology. However, developed by Omachonu and Einspruch2 has for health advocacy in the community6, “technology” has been used as a key term by been the basis for understanding healthcare now delivering a wide range of services from the interviewees when addressing the issue of innovation. However, Rogers’s idea of the traditional prescription dispensing to integration among healthcare providers: A diffusion of innovation (1995) has been clinical services. National Health Services new form of communication about patients’ considered to assess whether LPS follows England is assigning major efforts in health driven by technology is suggested to be the same pattern as business-technology- preventing avoidable illnesses, improving employed to ensure effective communication driven innovation. Finally, since LPSs are the health of the nation while sustaining among providers. This solution would also commissioned to tackle health disparities the government’s financial austerity policy. support the development of integration and to provide patients with wider choice To do so, more responsibilities are given to among all healthcare providers. LPSs are and easily accessible preventive services, this the local health government entities (LAs commissioned to meet the needs of the study investigates whether health inequalities and CCGs), which aim to offer integrated population, but their variability in regard to are in fact reduced by the presence of LPSs. services for communities by understanding what is offered causes them to have a high To define more precisely this study’s their primary clinical needs. In this context, number of local commissioning services focus, the three kinds of clinical services community pharmacies are regarded as the which are not advertised correctly, leaving delivered by community pharmacies must be way to reach more patients and to improve the public unaware of what is offered in clarified: their wellbeing. the pharmacy. This widespread lack of •National commissioned services or Research Questions: knowledge is a further lost opportunity for national services are terms used to refer The research questions are based around expanding preventative measures, since they to those services commissioned by NHSE the researcher’s personal experience in dealing are underutilised as a result. nationwide. with the implementation of LPS, and a •Private services are services offered review of the existing health literature which 2. Context independently by community pharmacies. does not include discussion on the present The United Kingdom health care system Thus, these services are not free of charge role of the community pharmacy and LPS. is characterised by the only state provider to the patients since they are not sponsored Therefore, these topics have been explored named National Health Service (NHS). directly by NHSE. with the guidance of business concepts, The NHS health care system makes citizens •Local pharmaceutical commissioned which aim to fully uncover the following recipients of free care, regardless of their services (LPSs) is the term used to describe research questions: socioeconomic status, while simultaneously the small-scale services commissioned locally 1. What is the current perspective on attributing to them the role of contributors by (mainly) local authorities (LAs) and the role of the Community Pharmacist in to single-payer insurance8. NHSE has

3 Journal of Undergraduate Research – Volume X Health Sciences

The Community Pharmacy Forward View18 proposes three core roles indicating what a CP should be: 1.‘The facilitator of personalised care for people with long-term conditions’, 2. “The trusted, convenient first port of call for episodic healthcare advice and treatment’, 3.‘The neighbourhood health and wellbeing hub’. The achievement of the cited goals is an ongoing process supported by the transformation initiatives such as new care and prevention programs developed by NHSE. The Community Pharmacy Forward View is built on the path set by NHSE’s 5YFV. The latter argues that change is needed in how healthcare is managed. Preventable illnesses are widespread, and health inequalities are deeply rooted across the country. A new model of care must emerge to ensure that quality care and new and better treatment are available for the Figure 1. 10-year Timeline of NHS England Policies Changes population. Thus, pressure on services to encountered many issues, four predominant improving their outcome satisfaction15. ‘One meet these demands is building. The primary ones being as follows: financial pressure, an size doesn’t fit all’. This simple statement aim in the 5YFV is prevention, which is an increasingly unhealthy population, rising probably best expresses the NHSE’s different achievable goal if integration of primary care waiting times, and health inequalities. services, established throughout the counties services into the role of CPs is created. NHSE NHSE was supposed to be a small health to deal with health inequalities, which are is now working to grant local authorities, care system, but now it has grown, so the defined as follows: ‘differences between CCGs, and local communities more short-term financial pressure is a major people or groups due to social, geographical, authority and independence in managing the challenge in NHSE operations. The budget biological factors. These differences have a needs of local populations. In this setting, gap increases year over year; it has been huge impact because they result in people community pharmacies play the critical role forecasted that the gap could deepen to who are worst off experiencing poorer health of the first point of healthcare advice, where over £10 billion by 2021–20229. The UK and shorter lives’16. the clinical services delivered aim to prevent is experiencing a huge rise in an ageing and To overcome the previously mentioned illnesses (e.g., flu services), manage chronic multimorbidb population while spending challenges, NHSE has revolutionised its conditions (e.g., anticoagulation services), just 8.4% of its GDP to fund NHSE. The modus operandi, allowing a devolved and promote wellbeing (e.g., health check Office of National Statistics11 reported 23% structure to exist that can effectively meet the services). In the current context, locally potentially avoidable deaths in England clinical needs of a specific area. The NHSE commissioned services ensure that CPs and Wales. These deaths, usually linked to has set up its goals in the 5YFV and plans meet the needs of patients by providing heart disease, stroke, and cancers, can be to receive efficiency savings that will allow it well-rounded services. In England, LPSs avoided by the patients’ pursuing a healthier to face the 2020 budget gap by shifting the are free of charge for patients, which should lifestyle. Just in England, the costs of ‘lost provision of services to preventive measures ensure service utilisation and positive health productivity from premature mortality and and by empowering patients, carers, and outcomes, such as compliance in disease sickness absence resulting from physical communities with their health through management in line with NHSE’s goals. inactivity’ has been estimated to be £6.5 accessibility and education about conditions billion per year12. Moreover, there were and personalised care budgets. In 2012, 3. Review of Relevant Literature 3.8 million patients waiting for treatment the Health and Social Care Act (HSCA)17 3.1 Developing Integration in June 2016, the most patients reported introduced the creation of local bodies across Drucker19 describes difficulties in waiting since 200713. Queuing is the control England, called Clinical Commissioning healthcare management as a ‘two-headed element for care access in NHSE. Without Groups (CCGs). A CCG’s role is to improve monster’ to express the idea of conflict it, everyone would have instant access to care the health of the area in which they operate between medical and non-medical staff. This at no cost. Arguably, a lack of restraint would while running on efficiency savings in favour idea can be applied to the context of the lead the UK population to overuse the health of NHSE. The services are commissioned to National Health Service England (NHSE). care system, broadening the NHS’s financial hospitals, voluntary organisations, and—of Since CPs are not directly NHSE’s employees, gap even further. However, the presence of central interest to this research—community dual complexity in the relationship between such long waiting times does cause mental pharmacies. As NHSE aims to focus on GPs and CPs may arise. The two healthcare and emotional distress for patients14. prevention, clinical services in community providers belong to two separate organisations Once the element of time is involved, pharmacies respect NHSE’s vision, since which operate differently, and they offer there are accompanying opportunity costs. they aim to detect illness conditions at an patients similar clinical services (e.g. Flu Improving patients’ waiting times leads to early stage and therefore prevent illness, vaccination). Therefore, the integration better efficiency, thereby reducing negative easing the pressure on GPs and positively process may result in difficulty if competition impacts on patient welfare from queuing and reducing the opportunity costs of the GPs. is present. For instance, in relation to LPSs,

Journal of Undergraduate Research – Volume X 4 Health Sciences clinical CCGs and local authorities open the Taran et al.21 stated innovation is the the path to reach fully transformed or new bidding process to any qualified providers change that occurs in the way businesses services. For example, the anticoagulation (AQPs), either pharmacists or doctors, to operate. Therefore, they analyse the level of management service provided by CPs in increase the patients’ choices. Hence, the change to describe the level of innovation England has now introduced novel oral topic of creating business relationships via a three-dimensional approach, first being anticoagulants (NOACs), which has meant among healthcare providers is explored in the innovation’s radicality or the level of that routine coagulation monitoring is no relation with the competition that may exist newness.c The second dimension comprises longer needed, resulting in lower costs in the in this environment. the reach of the innovation. So, it poses long run for anticoagulation management. 3.2 Healthcare & Business Innovation the question of whether the innovation is 4. Methodology Healthcare innovation framework new to the company or to the world. The The starting point of this research is the proposed by Omachonu and Einspruch2 is third and final dimension is an innovation’s experience gained by the researcher working presented as lens through which to visualise complexity, which is assessed via the change in pharmacy operations and implementing healthcare innovation. The characteristics of in the organisation’s building blocks. The LPS in the community pharmacy stores innovation are traced as described in certain ideal types of innovation are related to of a private company, referred to under business models. In this discussion, the their success rates, and success seems to be the pseudonym PharmaOne. This study is healthcare innovation framework is assessed determined by radicality and reach. On rooted in the current community pharmacy in contrast to business innovation models. It the contrary, complexity does not admit of and NHSE context. Thus, by analysing the is argued that healthcare innovation follows strong evidence to explain the differences current insights of experienced professionals similar ideas to those expressed in business between success and failure. Taran et al.21’s who cope daily with contextual changes in innovation models. The same aspects are research introduced the concept of successful the community pharmacy field, the lived reconsidered in light of the dissertation’s innovation, linked by evidence based on experiences of the CPs and their employees findings, specifically in relation to the clinical the radicality and reach of the innovation. can be presented. services delivered by the CP. This evidence aligns with the healthcare Interviews were conducted with 11 The provision of health care must be innovation framework, as one of the purposes members of a private pharmaceutical retail driven by innovation to ensure effective of healthcare innovation is healthcare company (PharmaOne) and one Clinical care for patients, as planned in NHSE’s outreach. In this case, something is defined Commissioning Group (CCG’s senior business objectives. This research considers as healthcare innovation just when it meets leader). The primary goal of this research is the presence of innovation in clinical services the requirement of accessibility. In fact, if to evaluate the role of LPS in the current delivered by the CP and their characteristics innovation is not made commercially feasible rapidly changing context of NHSE. The topic against the conceptual ideas of healthcare for public use, it can’t be deemed innovation is mostly unknown by the public and, due innovation. Innovation is defined ‘as those as it does not present the characteristic of to the complexity of NHSE restructuring, changes that help health care practitioners being utilised by the target group who was is difficult to interpret without first-hand focus on the patient by helping health care supposed to enjoy the benefits. experienced as guidance. As a result, professionals work smarter, faster, better, The cycle of innovation described in this interviews offered the most appropriate and more cost-effectively’20. The healthcare chapter follows process improvements rather method for exploring this low-profile innovation present in clinical services and than disruptive innovation, as often seen topic. Therefore, the researcher opted for delivered by CPs can be conceptualised within in customer goods. In fact, clinical services flexible data categorisation using a Thematic the framework of healthcare innovation provided in pharmacies are based upon Analysis. The emerging themes identified are (Figure 2). This framework pictures health existing technologies and never undermine listed below and are discussed in Chapter 5: care innovation as the result of two external the status quo of the firm. Barras22 stated that - the role of the CP and their integration forces, providers and patients, whose needs the cycle of innovation in services is the reverse with GPs, and capacity of adaptability are the inputs for of the product-cycle theory. Therefore, the - innovation in LPSs, and innovation. However, their role is reciprocal: first stage of service innovation is based on - how healthcare inequalities are tackled They are both the catalysts and the recipients the objective of increasing the effectiveness by LPS. of innovation. Innovation must answer of existing service delivery by designing new questions about how the patients are seen, technologies. In the second stage, technology 5. Analysis and Discussion how they are heard, and how their needs are is applied to improve the quality of service; The NHSE has recently undergone a met. in the third stage, technology is seen as devolution process aimed at empowering localities to directly address local needs and increase preventive measures, to ensure a healthier population. Within the local needs context, the topic of innovation present in local pharmaceutical services (LPSs) is explored, along with how health inequalities are addressed. Firstly, the discussion will focus on the integration between CPs and other healthcare providers. An account will be provided of the perspective of CPs of their working realities, as seen through the eyes of the interviewees. Secondly, the concept of innovation as an element present in LPSs will be unpacked about how innovation is present in LPSs and how this affects the population. Figure 2. Conceptual framework of Finally, the topic of health inequalities will healthcare innovation2

5 Journal of Undergraduate Research – Volume X Health Sciences be addressed in relation to the role of LPSs the ones delivered by GPs, at the moment, pharmacy has different types of medicine, via interviewees’ experiences. and not taking anything away from them’. but they don’t always realize that they can go 5.1 What is the current perspective on the role (Roberta) there for other things, such as the flu vaccine. of the CP in delivering clinical services and the In line with Roberta’s view, and as I think that it’s educating the population: go integration with the GP? expressed in Chapter 2, the role of CPs to your pharmacy for advice and services’. As noted in the literature review, the changed radically, with higher responsibility (Leonor) NHSE’s plans foresee integration between being placed upon delivering clinical services. In summary, a dichotomy exists healthcare providers. There are many Eades, Ferguson and O’Carroll24 concluded regarding the CP’s role. The evolution of advantages to this proposed integration, that although health policy changes support the CP’s responsibilities and the changes from reducing service delivery pressure from increased responsibility being given to implemented by the NHSE, both in clinical GPs, to heightened well-being throughout CPs, the pharmacists themselves were not terms (high numbers of LPSs commissioned the population via delivery of clinical services confident to deliver the clinical services. and independent prescribing) as well as in in community pharmacies. However, before However, the present study found complete the compensation framework implemented, commenting on provider integration, the agreement between all interviewees that CPs have allowed the role of CPs to be shifted role of CPs and how this role supports the are confident, willing and ready to deliver towards patient care. However, this extension NHSE plan in delivering clinical services clinical services; ‘We’re working and offering has not been fully appreciated by the must be understood. Firstly, the role of the more clinical services’ (Roberta). The ideology customers, as they do not realise what the pharmacists will be discussed regarding behind pharmaceutical care symbolises the CP can offer them. It has been postulated whether integration is feasible based on holistic nature that pharmacies are trying that the pharmacy culture must adapt their ability to deliver clinical services. A to achieve. The pharmacist’s role, rather in order to foster the implementation of discrepancy has been noted between what than being seen as sharply defined, could practice change26. Thus, although the health CPs can do and the population’s perspective support services and the overall well-being policies provide CPs with the opportunity to of their ability. The presence of integration of the community. This broadening of the deliver clinical services, customers and clients between healthcare providers, mainly CP’s role represents what can be considered a have not understood this cultural change GPs and CPs, will then be assessed via the sign of ‘professional maturity,’ stepping into and believe the CP is mainly a ‘medicine framework developed by Tuten and Urban1 holistic patient. All the interviewees agreed dispenser.’ Therefore, prior to addressing the to recognise whether healthcare integration that the pharmacist is able to take on more topic of integration, a clear issue must be follows the same antecedents used to build responsibility in the aftermath of becoming highlighted from the data, that health policy successful ‘business to business’ (B2B) the frontline of prevention and ensure may change but a shift in patients’ perception cooperation. welfare gain: of the true abilities and readiness of the CPs 5.1.1 ‘People tend to overlook what a ‘We want to support the NHS agenda. to support their health is needed to fully community pharmacist can do for them’ Obviously, we are aware of the ability and prepare for integration. The following section (Nazli) challenges within the NHS. They’re trying will explore the current situation regarding Before commencing integration between to commission some of the services. I think healthcare provider integration and the key healthcare providers, such as GPs and CPs, the pharmacies are relying correctly to [offer] conclusions drawn. individuals must have a strong confidence in support [in] the way they can […]. I suppose 5.1.2 ‘There is a role that is missing to the ability of CPs to deliver clinical services. because the pharmacies are open more hours, facilitate community pharmacy across primary All interviewees affirmed the ability of the they are able to reach the population easily. It and secondary care’ (Ainhoa) CPs to deliver clinical services. Thus, on makes sense for the NHS to commission that Healthcare integration is the the basis of this ability, the NHSE hopes to services that can be delivered by healthcare development and implementation of reduce the pressure that GPs currently face professionals. I think at the same time, the interconnected working relationships and to simultaneously improve the health pharmacies are really interested in supporting between providers aiming to enhance of the population by encouraging access to the NHS agenda because community population health. Schindel et al27 conducted preventive care23. Increased responsibility pharmacists have the education and the skills a study based on the perceptions of the is to be given to the CPs via health policy to do so’. (Nazli) pharmacists in the eye of the community after changes, so that they can offer additional Despite the potential identified in the an extended role, in terms of clinical services clinical services. This action will also lead the CP’s role, which was shared by all professionals delivered, had been implemented. The public CP to be considered a healthcare provider, interviewed, the wider population does not embraced the benefits in relation to the CP’s and CPs will theoretically be included in hold a similar view. Iversen, Mollison and ability to perform them due to legislative the healthcare provider integration process. MacLeod25 reported, regarding the public changes. As discussed in the previous section, CPs, via the delivery of clinical services, view of the role of pharmacists, that while the legislative changes desired by the NHSE can offer and promote health screening and customers seem to appreciate the role of aim towards healthcare-provider integration. overall well-being evaluation. They can form the CP towards a healthy-living plan and Integration is currently a priority in many the front line to improve the health of the supporting the work of GPs, they do not countries; however, none have developed a nation, as described by Roberta: seem to fully appreciate the ability of the comprehensive model. The clinical benefits ‘I think that’s where the way community CP to provide extra services in relation to of integration have already been studied, pharmacy is going, and actually a lot of the medicine management. Over 15 years later, from palliative service care28 to the successful pharmacies are looking to almost change the and after all the policy changes implemented management of dyslipidaemia29. Examining way that we’re working and offering more by the government, the interviewees agreed the concept of integration purely from clinical services. Pharmacies made that the that a mismatched perception of the CP’s the business perspective, it was evaluated right thing for the patient. Second, it makes role exists: whether NHSE healthcare integration was pretty [sic] much more sense for customers. ‘I think a lot of it comes down to letting created following the same pathway used I guess an example is the many community patients know that pharmacists are capable for B2B cooperation. Tuten and Urban1 services delivered which are the same as of doing these things. People see that a identified the antecedents of a successful B2B

Journal of Undergraduate Research – Volume X 6 Health Sciences

Tuten and Interviewees relationship (Chapter 3). Table 1 showcases Urban (2001) the elements cited by Tuten and Urban1 necessary to create a successful partnership Desire for lower ‘One way to avoid that higher cost is to involve pharmacy more but because of that ✓ in parallel with the interviewees’ responses costs, e.g., it means that some of those role boundaries start to blur and GPs are independent when asked about the relationship between reductions in contractors to the NHS and pharmacies in the main are mostly run as corporate GPs sand CPs. duplication of bodies or private individuals.’ (Matthew) Integration leads to the clinical effort, paperwork ‘A lot of services are provided in hospital or provided by a GP surgery, which advantage of patient care, in addition to the and inefficiency actually could be provided by community pharmacy. Transforming the way that benefits of efficient saving. Almost all the you provide services and making sure these services are provided where the patients antecedents discussed by Tuten and Urban1 need them, but also by a professional that can provide it, as opposed to getting were mentioned in regard to the relationship the most expensive professional to provide it, will free up money for community between CPs and GPs. The business pharmacy and the services. It’s about shifting where services are provided from’ advantages of cooperation between providers (Ainhoa) are clear to experienced professionals. Providing increased ‘Pharmacy has been able to show what it can do in terms of being closer to the ✓ Interestingly, the interviewees did not service—such as patient, quicker to respond to health conditions and like doing a bit more around mention the final antecedent. The reason meeting customer the prevention of the flu vaccination’ (Jude) for this may lie in the characteristics of the needs better ‘I think, well not think, I mean the integration across the whole of the healthcare questions asked. This research investigated and increasing providers is key, because you can’t just in isolation look after an individual. integration within the healthcare market. convenience Community pharmacy has probably…. limited access to understanding the whole In a Beveridge system, as with the English healthcare needs of that individual. It’s actually having that collaborative approach example, competition was introduced by the with those healthcare professionals, we need to refer as appropriate and [provide] government based on quality, as quality is 30 support for the appropriate’ (Stella) higher in competitive markets . Therefore, clinical services (e.g., anticoagulation) will Improving ‘When you are delivering service x…there’s a commercial reason to do it in a ✓ be awarded to the most qualified provider. performance pharmacy you see the till. In a GP’s surgery, you don’t see the till’ (Jack) Thus, gaining a competitive edge when indicators— ‘Pharmacists would be looking to increase their commission services, they get offering clinical services does not fully reflect including sales, remunerated to offer them’ (Ainhoa) the business competition characteristic market shares, and of self-interest. Healthcare in a Beveridge profitability system is seen largely as a right provided Increasing product/ ‘We also have a local enhanced service for supplying quite unusual drugs for people ✓ by the government rather than goods to service quality who are dying, palliative care services. When patients are in their last few days be traded. Thus, from a purely theoretical or weeks of life, they need some really quite strong painkillers and some sickness perspective, market competition should not medication and these are products that are normally stocked in pharmacies’ (Ben be present in healthcare provider integration, -NHSE) as healthcare providers are working towards ‘There are some services that a pharmacist can do that doctors are doing a lot more the improvement of the country’s health. of or anyone else in the practices like flu or like anticoagulant, we can do that a lot It was interesting competition between easier and quicker in our pharmacies. We’ve proven that and we’ve got evidence on GPs and CP was mentioned. The presence that and how it’s so much easier, more accessible, and frees up the GP’s time and of competition has been suggested to be one actually, in that case, it does make a lot more sense for some clinical services to be of the key obstacles that frustrate integrative done in pharmacy’ (Roberta) development. Gaining various ‘The GP understands, where the pharmacists can really help them and support ✓ ‘If we can get rid of that competitive benefits of a them with their patients, the GPs are understanding what services are available nature and integrate the ways of working to relationship with a through the pharmacy like your vaccination service’ (Jack) make it in a win-win for both‘. (Jack) partner—synergy ‘That really strong relationship is more complacent. You also have the opposite end ‘You get this sense of tension between between firms, of the scale where GPs are there, fully aware of that CPs are there, all those other the professions that sometimes gets in the and a trustworthy pharmacists that would have always and historically stayed with them. More of way, as everybody’s struggling to survive a lot partner. their [CPs’] patients are coming to them, they’re probably effective the moment of the funding shortages within the NHS’. that they have come in to their surgery ‘cause CPs and GPs exchange information. (Ainhoa) There was another side to that where it took a lot of pressure off them [GPs] [In relation to Any Qualified Provider since that time. Although, yes, they get less flu jabs, but also that they have more Contract – LPS] ‘Sometimes it could be appointments available that the next other patient could be sitting in the pharmacy. interpreted as a competitive threat, then that It depends on the education I think the treatment of patients is getting better when doesn’t exactly foster an environment of good there is this integration present ‘ (Leonor) relations for the healthcare professionals working together’. (William) Enhancing Not mentioned and not applicable to this study 푋 It is evident that the presence of competitive competition between CPs and GPs does advantage—such affect their working relationship. If tension as maintaining and threat are experienced, full integration a discernible may be a more distant prospect than first edge relative to thought. Therefore, while the NHSE plan competition for integration between healthcare providers Table 1. Similarities and Differences between business framework elements regarding B2B has been conceived as an effective solution relationship1 and interviewees’ responses concerning healthcare providers’ integration. to reduce costs, especially in preventive care,

7 Journal of Undergraduate Research – Volume X Health Sciences the reality of competition may undermine as possible for GPs and the various other ins remain in a peripheral planning position. this plan. and outs, secondary care. However, there Therefore, integration between GPs and CPs Two further elements were discovered are some areas that the pharmacy has been may involve a greater use of resources, either underlying this competitive feeling. able to show what it can do in terms of being money and time, than originally forecasted Firstly, competition was presented by the closer to the patient, quicker to respond to by the NHSE. interviewees as a lack of understanding health conditions and like doing a bit more 5.2 In which forms is innovation present in between the support of the CP for the NHSE around the prevention of the flu [with] LPSs? plan to open up patient choice of provider. vaccination’. (Jack) In business services, market orientation The NHSE allows companies to offer clinical The interviewees agreed that considering impacts the innovation process35. This services as GPs to open up that patient’s the national plans of the NHSE, community insight also holds true when considering choice through enabling a fair way to leave pharmacy potential is being lost since no the healthcare environment, as highlighted the choice of provider to the patient. holistic plan exists to promote its role. When by the healthcare innovation framework ‘At the end of the day, it is patient’s examining the reasons for not including conceptualised by Omachonu and choice whether they go to a GP, whether CPs in the wider plans for a primary role, Einspruch2. After some consideration of the they go to a health store, whether they go to the unhealthy financial state of the NHSE role of integration, the topic of innovation a local pharmacy. I think with any clinical was blamed. The funding priority is the in clinical services delivered by the CPs was service, it is tried to be done on [the basis of] hospitals. To increase the services delivered discussed with the interviewees. Interviewees fairness, so actually it’s not direct referrals to in pharmacy, a proportion of the budget agreed that innovation is present in LPSs and a pharmacy or direct referrals to hospital or must be taken from hospital services by, stated the logic behind their answers. It is GP, but it’s done in a fair way for both the for instance, a diversion of funding that generally believed that local pharmaceutical provider as well as the patient’. (Roberta) England is unable to afford. Integration services allow innovative treatments to be ‘I think any qualified provider [contract] may seem an impossible goal to achieve in widely accessible to the population. (AQP) allows patient choice. It’s a mechanism the short term. However, thanks to insights ‘I think locally commissioned service for providing greater choice to patients for from an experienced professional working in [Local pharmaceutical services] and private the services they need. By qualifying as an relation with Manchester Devolution (‘Manc services allow for more innovation because AQP provider in accessing services, you Dev’), attaining integration appears to be they have developed locally. They meet local are then able to advertise your services to closer. Manc Dev allows the area of greater needs. What you need to remember with the patients. I guess the GP is providing the Manchester to be in charge of the social and NHS is that it is formed at a local level, and a service and providing the script, so the healthcare budget. Due to this responsibility, lot of the care pathways between localities are patient may feel more loyalty to remain with the commissioner in charge has called for so different. Rather than changing everything surgery, and it’s up to the other providers to integration between hospitals, GPs and and having a blank sheet of paper, you build sell in the benefits of why the patient could CPs in providing services such as social care pathways on what’s there currently and choose [them]’. (Ainhoa) prescribing and well-being plans. Manc what the patients are used to, and you try to Opening up patient choice regarding Dev may appear to be the path to efficiently improve them. Therefore, local commissions provider has been seen as a way to encourage manage integration, offering a way to use and private services can enable you to do that providers to be more responsive to patient underlying assets such as CPs. However, and provide the local flexibility to meet local preferences about how and where health care Mach Dev is the only example of healthcare needs’’. (Ainhoa) is delivered31. Moreover, allowing patients devolution now present in the UK, and it is Ainhoa’s claim is supportive of the to choose their providers encourages these only now actionable after years of planning. conceptual framework of healthcare same providers to respond in improving The road to integration may require years; innovation2, since the role of patients is cited their quality in order to remain in the market therefore, a short-term solution must be as the reason for why innovation is strongly and attract and retain patients32. Therefore, found, especially when Brexit consequences present in private services and in LPSs. In fact, allowing patient choice is beneficial to may negatively affect NSHE research and the framework clearly shows that innovation patients, providers and to social welfare development, as well as its budget33. A short- is driven by how the patient is seen, is heard gained thanks to the quality improvement term funding solution may be found to and how his/her needs are met. Moreover, of service delivery. Indeed, community overcome the budget gap; however, this may the idea of clinical services provided by a pharmacy is transforming, but it still sits in involve a tax increase, which according to the CP following a service improvement path the shadows, and is not taken account of in new government plans will solely support was confirmed: ‘You build care pathways on the national plans. NHS operations34. what’s there currently and you try to improve ‘Right, community pharmacy is— In conclusion, the data obtained here them’ (Ainhoa). Therefore, the first stage of there’s somewhat on the periphery of these indicates that the path towards integration the reverse cycle of service innovation (see 22 changes, GP services are included, but the is more complex than simple policy Chapter 3) is fulfilled. The effectiveness of the other three independent contractors’ services implementation. Although the benefits of service is in fact increased by adding improved and primary care are currently not included, partnerships are appreciated, the presence elements (applying new technologies) to the although we are just at a point now where of competition between GPs and CPs is an existing service rather than via a completely we’re reaching out to them and starting obstacle for strong working relationships. disruptive innovation. to have conversations with community While the NHS is attempting to broaden ‘They [LPSs] absolutely are innovative, pharmacy about how we can bring them in’. patient choice by assigning clinical services […] like self-testing. That I believe, that I’m (Ben) to CPs, this action may unintentionally lead aware of, is only operated in Bucks field, but ‘‘I don’t think the NHSE team was to competition to obtain patients, rather as that grows over yet, learns a lot, it may planned; they fully realized what pharmacy than appreciation for the benefits in terms turn out to be the best thing for the patient; can do for them. I think very much it’s still of service quality and reduction in delivery it empowers the patient’. (Leonor) the primary and secondary care and trying pressure from a GPs perspective. Moreover, it ‘I think the biggest thing we’ve seen in to manage everything through or as much has been noted that community pharmacies regards to innovation is things like our anti-

Journal of Undergraduate Research – Volume X 8 Health Sciences coag services. In a GP surgery or hospital multiply by 10%, 20%, 30%. Those are method of communication. In this era you have to have a full phlebotomy, blood people, so it is multiplied by 10 or 20. It has of technological processes, using ‘a piece test, and then the test results get sent off and a huge impact when the service is free or paid of paper back to the general practice’ to it could take a couple of days, sometimes by the privileged health system; you really see update patient records is not only open to maybe even a couple of hours, but [after] a the number of services delivered increase by a breaches of confidentiality, but can also be couple of days it comes back, and by then significant amount of time in the population. considered a waste of time for the healthcare your INR could be over or under and that, When you move to policy-based service, you professional. Drucker39 advanced the [which] could be life-risking. Whereas in have the typical curves of people who are importance of effective information sharing pharmacy now, you can go in, have a blood using your service’. (Nathan) for healthcare professionals, as they work in sample taken and get your INR tested there Therefore, publicly-founded services, a high-level information-based field. Despite and then within seconds. It’s a (sic) 100% as they eliminate any financial barrier in CPs delivering clinical services, they are not proven, so I think that’s innovation. I don’t accessing the innovation, see high number granted access to patients’ health records think we do enough of it, I think there are so of customers utilising the service. It can to adjust their care accordingly, ensure that many other things that we could potentially be argued that, from the moment a service correct patient health-related information do, whether it’s around diabetes or other is publicly funded, the patients belong to is exchanged, or ensure up-to-date records. tests that we can do in community pharmacy the majority phase, if compared to Rogers’ The desired technological process would that we just haven’t gotten quite there yet, diffusion theory37, with no innovators or early support information-sharing and improved but there are other things we can do, and I adopters. On the contrary, private services, communication between CP and GP, think anti-coag is a great example of what as they are not free of charge, experience reducing inefficiency and driving innovation. community pharmacy can achieve. I think that the patients behave in the same way as 5.3 How do LPSs support the fight against independent prescribers in a walk-in clinic in the customers described by the diffusion of health inequalities? a community pharmacy is an excellent idea, innovation curve by Rogers. Health inequalities have been a topic of and we’ll be doing that, for example, in the When the topic of innovation was raised health policy discussion for over a century anti-coag, but I think we could do it in more. in the context of LPSs, the technological with no optimal solution found yet. The We do offer minor ailment schemes where advancement of communication between Acheson Report40 documented the presence we can offer antibiotics which is [sic] usually healthcare providers was highlighted. of health inequalities in England, which were prescribed by a doctor, but you can do it on Local pharmaceutical services, such as the derived from social inequalities (income, specific tests. Other services that we do are anticoagulation service or health checks, social status). Bambra et al.41 suggested that the throat test and treatment service, which require the two healthcare providers to social interventions based on promoting the is very new; it was a trial done in London’. communicate the health records of the greater well-being of disadvantaged groups (Roberta) patients. There is currently no digital may reduce the health gap. LPSs have been Independent prescribing (IP) and form of efficient communication between contracted to tackle the specific needs of patient empowerment have been mentioned providers except for the proposed EMISe the population, and thus to reduce health as the most common elements of innovation solution for GPs. Zerfass and Huck38 argued inequalities in given communities. in LPSs. Empowerment is considered that communication is a key factor to ‘They tend to find that the local successful in managing long-term conditions innovation management promotion. Being a commission services are commissioned in in patients with diabetes mellitus, which communication promoter would lead to the response to a local need, and therefore, by also positively affects the psychology of the simplified sharing of new ideas, technologies, their very nature they’re addressing health patients36. Empowerment is an effective products and services with followers. inequalities. By addressing that need, if philosophy, yet few programs implement it. ‘So, you have currently a shift in the you just think of emergency hormonal Moreover, the innovative aspect of allowing population in favour of digital changing the contraception, that service’s very often CPs to be prescribers further integrates with channel. So, the pharmacist has to be part formation (sic) is in response to high levels the practical necessity of efficient GP time of this shift, or they can really improve their of teenage pregnancy in a particular area. management and improved patient care. position in the community by being part of To make access to that contraception easier Although IP and patient empowerment are this move. If they are not, if they don’t do to people, and help contribute to reduce innovative elements, the technology behind the work, we can imagine that it won’t be the teenage pregnancies, just the standards of innovative services in pharmaceutical services GPs, it won’t be the pharmacists, but it will very common pharmacy services like that is already present. Innovative elements allow be the digital platform that will deal with the over two years are impacting local health service quality to be improved, completing the health of patients. At the moment, I’m not inequality’. (Jack) second stage of reverse service innovation22. so sure that it will be beneficial for patients’. The health needs of an area must be LPSs and private services allow technological (Nathan) understood by the NHSE to allow proper drive to be provided to the population due to ‘We’re going to use them to do some services to be commissioned. For this reason, the accessibility of pharmacies. However, the health checks, take blood pressure, maybe the devolution action has been significant, two types of service appear to follow different do a diabetes test. Currently, the only way as clinical commissioning groups (CCGs) diffusion curves based on the health policy for the pharmacy to add that information are now in contact with the need of their upon which they rely. to the record is to basically send a piece localities. This has allowed preventive ‘We take technology which is already of paper back to the general practice, and measures to be built that ensure that necessary developed, where we improved, where we that’s not helpful to anybody, really. We do services are appropriately commissioned. innovate is when we put it in a pharmacy. need to progress nationally to a point where Further, the reasoning behind the concept of […] The services which are publicly funded community pharmacies can not only access LPSs addressing health inequalities is related always bring big volumes. In flu vaccination the record but can amend the record or to the accessibility argument presented by or MURd in the UK where they are publicly update the record’. (Ben – NHSE) CPs. fund community fund services, we saw The pressure to deliver clinical services ‘‘I think one of the key things is— the number of flu vacs. done in-pharmacy calls for an effective and technology-driven when we talk about inequalities—is the

9 Journal of Undergraduate Research – Volume X Health Sciences accessibility, the accessibility of the services, shrinking nationally. The changes in 2013 [are] available. That’s where national services because of the location for pharmacy within, certainly didn’t help because public health come in. It would make a sense to have whether it’s deprived locations, whether budget nationally has reduced. What we’re national services because then the public can it’s here. The different locations, they are grappling with locally is finding ways to really understand what is available through literally more accessible to a broader level use NHS money that’s previously been used pharmacy and all the pharmacies, and of the population. That was one of the real for care, illness services, and freeing that therefore access that more routinely’. (Jude) key benefits the pharmacy has over [other] money up to pay for well-being prevention In addition to the lack of funding issue, settings, whether that’s GP practices which services. That’s the right thing to do, but two major issues arose when considering are in certain locations, or like literally it does mean that we have to stop doing the role of LPS and health inequalities: LPS in certain locations, where you have one some things that we currently do. Good variability and the lack of public knowledge on large GP practice which actually fulfils the examples of that are in prescribing, we’ve LPS. Firstly, LPS responds to the need of the requirements of a significant geographical implemented normal policies in last year population. However, each commissioning area. Actually, it may not be convenient for where we’re actually stopping giving certain group provides contracts with different people to get to that, whether it’s because medications because we’ve decided they are eligibility criteria for the patients of an area, of the cost of the travelling, the ease of the not a priority and that it upsets people. We which differ from other areas. Therefore, travelling, the health issues that they have deal with complaints frequently about it, but there is contra-logic in the accessibility in getting there, community pharmacy and we have made a decision that we’re going to aspect. Although a service is accessible, if the a larger location just give that accessibility dis-invest in some things in order to reinvest eligibility criteria are different, the level of care convenience’’. (Stella) in other things, which are of higher priority. varies, and thus health inequalities may rise The accessibility argument referred That’s essentially what commission needs. even further as Matthew stated ‘they are all to by the interviewees is the geographical Commission is about deciding what are our done in a slightly different way. it adds more accessibility to care, which moves further priorities and then put[ting] in contracts and inequalities’’. Furthermore, this variability from the health economics access to care finance and all the support in place so that may not only raise heath inequalities, but hypothesis. This hypothesis, advanced the priorities that we’ve decided are the ones the administrative cost from the NHSE as within health economics, relates to the price that are provided. It actually means stopping Ainhoa’s interview draw attention to. For of accessing healthcare in other countries42. doing other things’. (Ben – NHSE) instance, the Anticoagulation service can have As England belongs to a universalised The financial pressure the NHSE is many variations depending on the drugs the free healthcare system, the access to care currently under undermines the commission CCG commissioned, the eligibility criteria hypothesis does not provide a solution to of preventive services. Simultaneously, the of patients and whether the service would the current health inequalities present in the budget will be prioritised to short-term goals, include independent prescribing by CPs. system. Therefore, the introduction of the e.g., chronic condition management rather The number of variations implies that for geographical accessibility argument in this than investing in long-term solutions such every anticoagulation service commissioned study may be an additional hypothesis to as preventive services commissioned to the the costs for the NHSE will differ. On the explore in the fight against health inequality. pharmacies (e.g. LPSs). contrary, a homogenous service throughout Murray’s review43 champions the role ‘‘I think this variability—I think they the nation would mean less administrative of the CPs in enhancing the healthcare of (LPSs) adds costing to the NHS. I think there costs to maintain as expenses will be kept the population, mainly due to their easily should be some standard contracts that you low. accessible presence in deprived areas. The can cut and paste clauses [from]. dependent Secondly, variability in providing accessibility argument in healthcare suggests on your specific needs. I think that could be services causes a lack of knowledge about that health inequalities are determined by facilitated as a higher level within the NHS. which services are provided. The lack of differences in access to care. In countries with You haven’t got people developing contracts awareness of the services is determined by universal healthcare, such as England, the up and down the country for the same sort of two factors: the lack of focus on advertising accessibility argument may not unequivocally thing’’. (Ainhoa) in the community pharmacies and the apply44. However, the presence of CPs in ‘The inequality’s often associated sort of lack of national coverage. According to the consideration of health inequalities with schooling, education, and those other Grönroos and Ravald45, potential clients and access to care has yet to be studied. areas, or possibly the long you have to wait gather information about the services, Recently, the positive results of better care to see your GP; Those are more extreme, I while the organisation exposes itself in a have been shown via the utilisation of think, than the actual physical access to the proactive manner via advertising, personal LPSs, such as lowering the rate of teenage services that typically pharmacies do at a selling efforts. When dealing with customers’ pregnancy by introducing an emergency local level. I don’t think it’s -- because though services, the two parties actively engage in contraception service. Despite the paradigms most of the big four or five local services are information sharing. However, this double of the accessibility of pharmacies and the done in most of the areas because they’re action may not appear in the LPS field, as role played by LPSs in focusing on local done all in a slightly different way. I think it there is a lack of awareness of what is offered health needs, health disparities persist, and adds more inequality to it because they’re not in the pharmacies. further reasons for these inequalities have all judging each patient on the same merits, ‘‘NHS Choices website, as long as been identified. The first factor relates to the even though the attempt was to remove that’s available from the pharmacy point of financial pressure the NHSE is facing: inequality’’. (Matthew) view that could tell what the national, local ‘[Local pharmaceutical services] will ‘‘That can be quite a confusing picture, services or other services are available from certainly help, but they’re not going to but just so, that exposes some of the counter- that pharmacy. Does the patient know what be the magic bullet that kills the issues arguments against having lots of different to look at that? Probably not. If you were to that we face. So, it will need a team-based locally commissioned services. Because the Google, depending what you Google, ‘what approach from all parts of the system really. public awareness of what is available then services available from my pharmacy?’ I don’t […] but the investment in well-being can be confused because you can go from one know what comes up. Or if you thought services and prevention services has been pharmacy to the next, and different services I’ve got a backache and you put in ‘I’ve got

Journal of Undergraduate Research – Volume X 10 Health Sciences a backache, what do I do?’ I don’t know if financial pressure, and the lack of exposure, going to be the magic bullet that kills the pharmacy would score in that. So, it’s a hard LPS may remain an afterthought rather than issues that we face.’ (Ben) one to answer, hard, because I know where being at the forefront of illness prevention. Local pharmaceutical services are you could look, if I wasn’t in this role would 6.1 Core Findings commissioned to answer the local need I know to look at NHS Choices and things The interviews made clear that the and to reduce health inequalities in specific like that? No, I wouldn’t’’. (Matthew) research questions offered a conversational areas. However, it has been highlighted The first website that interviewees starting point with industry experts. In how their variability may not only increase stated they referred to for information was fact, the research questions allowed the health inequalities, but also induce confusion NHS Choices. However, they agreed there interviewees to freely share their thoughts and to patients. There is no national website is a lack of information in the absence of a insights on the topic in question, but they clarifying which LPSs are provided where, national, comprehensive, information-based also took the time to explore the topics and and which eligibility criteria are included. website on LPSs. Moreover, Grönroos and the current reality in more depth. The data The most cited website to support health Ravarld45 suggested that in the climate of gathered interestingly challenge assumptions decisions in relation to access to care is NHS competitiveness, companies should not just on the role of the CP and LPS and show the Choice. However, this site does not allow a apply traditional service marketing, but gaps in the implementation process of the comprehensive view of LPS. Hence, while rather an interactive marketing function, national plans. LPS are directly commissioned to promote in which every component of the service ‘Relationships between the two [CPs health equity, the lack of awareness by the process (organisations, sellers, buyers) and GPs] are hit and miss.’ (Matthew) public of what is offered causes a loss of interacts not just in the selling encounter but From the interviews, it is apparent that welfare, as patients in needs will not utilise also in the consumption process. By allowing there is a discrepancy between what CPs can the services. Moreover, the variability among information to be found, customers’ needs do and what the public perceives they can do. LPS creates different eligibility criteria for are best met, and a relationship is created Moreover, while NHS’s plan is to integrate patients to access the service, which may with the customers that continues after the the role of healthcare providers to open the result in a rise in inequality. moment of purchase. Therefore, creating a path to complete care, the competitiveness 6.2 Core Contributions website for clinical services offered by CPs of offering clinical services may limit the Although earlier research into the role would be beneficial to both the NHSE, national plan. As cited by Matthew, CP and of the CP has been conducted (25,46), the as it would allow patients to easily access GP is a ‘hit and miss’, meaning that while majority of the literature is dated over three information, and to private retail pharmacies, the two healthcare providers are supposed years ago. It does not capture the current as it would drive sales. to cooperate in widening patient’s choices, climate of the community pharmacy. In While NHSE plans are directed towards their cooperation is not fully developed fact, 2013 marks a devolution action by the CPs assuming increased responsibility, there nationwide, thus missing the opportunity to NHS, when more responsibility was given to is a lack of confidence by the public regarding provide better care. local teams. The commissioning of services the capacity of the CP. Simultaneously, ‘It’s not a brand-new innovation that to community pharmacies has increased the integration path is challenged by the you do, that there is already some proof since 2014. Despite the programs of NHSE competition arising between CP and GPs of the interest in that innovation from a to consolidate the role of CP as a healthcare in providing clinical services and by the purely pharmaceutical, general perspective.’ advisor, there are issues related to public competitive nature of service delivery. (Nathan) perception. Moreover, whereas healthcare- LPSs are seen as introducing elements of The role of innovation in LPS is provider integration has been considered a innovation, which are characterised by pre- completely different from the idea of pure priority in healthcare efficiency, it does not existing technology made easily accessible novelty usually experienced in other sectors, appear to be a simple process, as elements to the community. Furthermore, the role as clearly stated by Nathan’s comment that of competition arise in the relationships of technology innovation in relation to ‘It’s not a brand-new innovation’. LPS between GPs and CPs when delivering providing improved information sharing allows clinical services to be accessible to the clinical services. The relationship between the between CPs and GPs in delivering clinical population. Patient-empowerment clinical two healthcare providers has been analysed services is needed. Finally, while LPSs may be services such as self-testing anticoagulation via the B2B framework1. The antecedents contracted to address health inequalities and or LPSs supporting CPs to take on the role of described in the framework have been ensure prevention services, financial pressure independent prescribers (IPs) have been cited confirmed to be present in the relationship and variability may negatively affect the as an example of innovation introduced in the between CPs and GPs, proving that NSHE plan and budget. LPS variability may community pharmacy. These two elements 1. integration is a feasible goal in appear to have the unintended consequence were suggested to be more inclusive when community healthcare. However, it is of leaving patients unaware of the available the NHSE commission a LPS. Moreover, necessary to ensure competition is mitigated; services. Neither CPs nor the NHS seem since enhanced services (e.g. anticoagulation) and to have implemented an effective way of necessitate the patients’ health records to be 2. the competition among GPs and CPs communicating which LPSs are available. updated, communication between GPs and can be analysed via business framework. The following chapter will present a CPs is necessary. It has been found that there Although, the topic on the research is relevant summary of the findings that emerged from is no system in place to ensure that the CP to the healthcare market, further research the collected data. tracks patients’ health information and health to alleviate the competitive nature of their records. It has been noted that technology- relationship could be explored, conceiving 6. Conclusion driven system encouraging GP and CP them as two business operating rather than This research also exposes issues around communication about health records could as healthcare providers. the gaps in the process of the integration not only represent an innovative element for of healthcare providers. Moreover, it shows LPS, but could also enhance the integration This research offers a small-scale how LPS may be the right way to tackle among the providers: exploration into the role of community health disparities. However, due to NHSE’s ‘LPS will certainly help, but they’re not pharmacies and local pharmaceutical

11 Journal of Undergraduate Research – Volume X Health Sciences services in the currently changing context. the funding and the research development possible short-term solution would be to set This exploration could be potentially useful available for the United Kingdom49. It an “NHSE tax” determined by each CCG. for policy when looking at the goals to would be useful to consider whether Brexit The NHS was originated after World War be achieved in relation to prevention and will have repercussions and if so, how these Two and did not forecast over 60 million integration. The path to prevention includes: repercussions affect the field of clinical people utilising it. • patients actively seeing CPs as the first commissioned services within pharmacies Throughout the research, the potentials point of advice and service delivery; once negotiation is over and Article 50 is of the CP and LPS to tackle the local needs, • GPs and CPs effectively communicating fully implemented. promote wellbeing and innovation have and exchanging information; and 6.3 Core Recommendations been shown and supported via business • accessible and clear information about To ensure providers understand that the frameworks, which have been found preventive services. delivery of services relates to the advantage applicable in the healthcare market. However, Despite the NHSE’s efforts, the data of opening patients’ choices, there should these potentials are not completely achieved suggests these objectives have not been be double the effort from CCGs and local due to lack of a fully integrated healthcare achieved. However, further research must authorities in partnership with the CP to providers’ system and the low-profile role be conducted to appreciate fully the issues ensure collaboration is present among the of LPS. There is a lack of awareness about and current progress toward solving them. CPs and GPs. The authority of the NHS what the CP can provide and the accessibility It could be useful in performing nationwide and the pro-activeness of CPs may lead GPs of LPS. Therefore, although CP and LPS independent research aiming to showcase to entrust CPs and to ensure proper referral could be key players in supporting NHSE’s national spending differences in health care, of patients to CPs. In this way, patients will higher goal of prevention, they are shadowed the services provided, and population health recognise the role of the CP in delivering by the role of GPs. Despite NHSE’s plans outlooks. This action would lead to further clinical services, and simultaneously, the GPs directed towards prevention, efficiency and transparency in NHSE operations and a clear will be able to effectively see more urgent cases. integration, CPs and LPS are still small fishes picture for health policy decision-makers. Nutbeam50 showed that the first step towards in the big pond of the NHS market. Since the Dartmouth Atlas project was firstly higher health policy goals, such as prevention published in 1988, it has been used as a tool programs and patient empowerment, is the Acknowledgements for American health policy, as it acknowledges transmission of healthcare information. I would like to thank all the healthcare the fragmentation of the health care system47. Creating a communal platform allowing the experts who volunteered to take part in A similar and consistent approach may be sharing of the availability of services may my research study as you all made me feel used by the NHSE to support their decisions be the right way to tackle the gap between incredibly welcome, and your contributions and policy goals. what is offered and what people know is have been invaluable. Investigation of the role of LPS in the offered. Moreover, due to the pattern of how I am extremely grateful to the whole JUR community environment has highlighted the we access information, promotion of health team, Katie Brown, Reagan Fitzke and the benefits of the geographical accessibility of prevention programs should be considered, external reviewers for using their expertise to the services as determinants to reduce health with use of multichannel platforms, such support the publishing of this research study inequalities. This argument introduces the as social media, via companies’ pages (e.g. – thank you for your amazing help! logistic of service providing rather than the PharmaOne). Furthermore, since NHSE costs associated to accessing care, which is is currently encouraging the use of the Footnotes aAnticoagulation is the ‘process of hindering the one of the hypotheses often mentioned in summary care record, the same electronic 3 health economics when exploring health record should be opened to CPs to ensure clotting of blood’ . The anticoagulation services ensure 42 patients with blood-clotting issues to be monitored and inequalities . The geographical accessibility precise judgement when delivering clinical managed in the community pharmacy. Around 1.3 of LPS has been cited as one of the reasons services and to update patients’ information. million patients are prescribed anticoagulant therapy in these services are determined by innovation, Interviewees agreed that this particular the UK4. bMultimorbid is commonly defined as the as they allow innovation to spread further data-sharing method could improve the presence of two or more chronic medical conditions into the community. The ‘outreach aspect’ effectiveness of communication among in an individual, and it can present several challenges is an element used to describe the process healthcare providers, although they also in care, particularly with higher numbers of coexisting conditions and related polypharmacy10. of innovation in healthcare of the both raised concern for patient’s privacy and c 21 2 In the business model developed by Taran et al. , healthcare innovation framework . However, ensuring that the patient understands the role ‘radicality’ is a critical variable which determines how the process of innovation spread follows a of CP. Data-sharing tools are controversial, much an innovation has departed from what was present different diffusion curve, depending on the and a security policy must be in place before before. health policy it relies upon. Rogers’ diffusion fully developing such a system. However, it dMUR, the Medicine Usage Review, is a nationally- theory37 is in compliance with how private has been proven to be extremely effective in commissioned service in which the CP completes an 51 adherence-centre review on the medicines prescribed to services are accessed; on the contrary, LPSs Australia . patients with polypharmacy, to determine whether the and national services, as they are free of The recommendations would need patient complies with the medication use and that there charge, attract patients independently and a double-effort of development and are no concerns arising from their use. eEMIS (Egton Medical Information Systems) do not respond to the same diffusion theory implementation from both private is a web system mainly used by physicians to update as private services. companies, such as PharmaOne, and NHSE. electronic patient health records. It also allows patients Finally, this research has been carried To improve the health and wellbeing of to book GP appointments online and order repeat out in 2016/2017, allowing it to consider the population, the NHS tries to activate prescriptions. fSummary care record is an electronic health the effect of the devolution action started in prevention programmes and to place greater record containing all the clinical information about the 2014 and to explore the recent changes in responsibility on the CP. However, due to care a patient has received. health care management (e.g. Manchester their limited resources, the budget is still Devolution48). However, 2016 marks also the streaming to hospitals and GPs. Prevention References confirmation of article 50 for Brexit. Brexit assumes a peripheral position. To overcome 1Tuten, T. and Urban, D. (2001) “An Expanded will likely affect the way NSH operates, the budget gap, funding is needed. One Model of Business-to-Business Partnership Formation

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and Success.” Industrial Marketing Management 30.2. (2016) “Provision of Clinical Preventive Services by England.” Pharmaceutical Journal. (Accessed 09/29/2016). Public Sector Innovation Journal 15.1. Pg 1-20. review of pharmacist and consumer views.” BMC Public 44Marmot, M., Stansfeld, S., Patel, C., North, F., 3Merriam-Webster.com. (2017). “Medical Health 11.1. Pg 1-13. Head, J., White, I., Brunner, E., Feeney, A., Marmot, Definition of ANTICOAGULATION.” “Attitudes of the general public to the expanding role of British civil servants: the Whitehall II study.” The Lancet (Accessed 05/03/2017). community pharmacists: a pilot study.” Family Practice 337.8754. Pg 1387-1393. 4Hammond, R. (2016) “Bridging anticoagulation: 18.5. Pg 534-536. 45Grönroos, C. and Ravald, A. (2011) “Service perioperative management of patients on 26Rosenthal, Meagen M.Breault, Rene R.Austin, as business logic: implications for value creation and anticoagulants.” Clinical Pharmacist 8.4. (Accessed 03/03/2017). 27Schindel, T., Yuksel, N., Breault, R., Daniels, and Community Pharmacists Working Together.” 5Pharmacy Voice. (2016) “Community Pharmacy J., Varnhagen, S. and Hughes, C. (2017) “Perceptions International Journal of Pharmacy Practice 6.2. Pg 60- Forward View.” Royal Pharmaceutical Society English of pharmacists’ roles in the era of expanding scopes 66. Pharmacy Board. of practice.” Research in Social and Administrative 47Smith, R. (2011) “Dartmouth Atlas of Health 6Anderson, C. (2000) “Health promotion in Pharmacy 13.1. Pg 148-161. Care.” BMJ 342.23. Pg d1756-d1756. community pharmacy: the UK situation.” Patient 28Bainbridge, D., Brazil, K., Krueger, P., Ploeg, 48Greatermanchester-ca.gov.uk.(2017). Education & Counseling 39.2. Pg 285-291. J., Taniguchi, A. and Darnay, J. (2014) “Measuring “Health and social care.” GMCA. (Accessed 02/07/2017). 8Hills, J., Ditch, John, & Glennerster, Howard. process within a palliative care network.” Journal of 49Edwards, N. (2017) “Brexit means... an uncertain (1994) “Beveridge and social security: An international Interprofessional Care 29.3. Pg 245-252. future for the NHS?.” The Nuffield Trust. org.uk/publications/decade-austerity-funding- 30Gaynor, M. (2006) “What Do We Know About (Accessed 04/29/2017). pressures-facing-nhs> (Accessed 11/14/2016). Competition and Quality in Health Care Markets?.” 50Nutbeam, D. (2000) “Health literacy as a 10Wallace, E., Salisbury, C., Guthrie, B., Lewis, C., National Bureau of Economic Research. Working Paper public health goal: a challenge for contemporary health Fahey, T. and Smith, S. (2015) “Managing patients with No.12301. Pg 3-28. education and communication strategies into the 21st multimorbidity in primary care.” BMJ 350.20. Pg 176. 31Dixon, A., Robertson, R., Appleby, J., Burge, P. century.” Health Promotion International 15.3. Pg 259- 11Office of National Statistic. (2014) “Avoidable and Devlin, N. (2010) “Patient choice”. King’s Fund. 267. mortality in England and Wales: 2014.”. Gov UK. . (Accessed A (2016) “Will the NHS be affected by leaving or network/2014/apr/22/controversial-data-sharing-good- 09/28/2016). remaining in the EU? Briefing.” London School of patient-health> (Accessed 04/22/2017) 12National Institute of Health and Care Excellence Economics and Political Science website. (Accessed uk/advice/lgb26/chapter/What-can-local-authorities- 06/30/2016). achieve-by-taking-action-to-reduce-premature- 34Parker, G. (2017) “Lib Dems propose 1 per mortality> (Accessed 09/12/2016). cent tax increase to fund NHS.” Ft.com. (Accessed 05/07/2017). (Accessed 35Agarwal, S., Krishna Erramilli, M. and Dev, C. 11/05/2016) (2003) “Market orientation and performance in service 14Carr, T. Teucher, U. and Casson, A. (2015) firms: role of innovation”. Journal of Services Marketing “Waiting for scheduled surgery: A complex patient 17.1. Pg 68-82. experience.” Journal of Health Psychology. Pg 1-12. 36Anderson, R. M., Funnell, M.M., Butler, P.M., 15Barlow, G.L. (2002) “Auditing hospital queuing.” Arnold, M.S., Fitzgerald, J.T. and Feste, C.C. (1995) Managerial Auditing Journal 17.7. Pg 397-403. “Patient Empowerment: Results Of A Randomized 16Nice.org.uk. (2012) “Health inequalities and Controlled Trial”. Diabetes Care18.7. Pg. 943-949. population health.” NICE. (Accessed York: Free Press. Pg 243-251. 1/012/2016) 38Zerfass, A. and Huck, S. (2007) “Innovation, 17Gov.uk. (2012) “Health and Social Care Act Communication, and Leadership: New Developments 2012: fact sheets.” Gov.uk. (Accessed 02/11/2017). 39Drucker, P. (1988) “The Coming of the New 18Pharmaceutical Services Negotiating Committee Organization.” Harvard Business Review. View.” PSNC. Pg 1-20. (05/07/2017). 19Drucker, P. (1976) “Managing the public service 40Acheson, D. (2000) “Independent inquiry into institution.” College and Research Libraries 37. Pg 10. inequalities in health.” London: Stationery Office. 20Thakur, R., Hsub, S. and Fontenota, G. (2012) 41Bambra, C., Gibson, M., Sowden, A., Wright, “Innovation in healthcare: Issues and future trends.” K., Whitehead, M. and Petticrew, M. (2009) “Tackling Journal of Business Research 65.4. Pg 562-564. the wider social determinants of health and health 21Taran, Y., Boer, H. and Lindgren, P. (2015) inequalities: evidence from systematic reviews.” Journal “A Business Model Innovation Typology.” Decision of Epidemiology & Community Health 64.4. Pg. 284- Sciences 46.2. Pg 301-331. 291. 22Barras, R. (1986) “Towards a theory of innovation 42Bhattacharya, J., Hyde, T. and Tu, P. (2014) in services.” Research Policy 15.4. Pg 161-173. Health economics. Basingstoke: Palgrave Macmillan. 23Kelling, S. E., Rondon-Begazo, A., DiPietro 43Murray, R. (2016) “Independent community Mager, N. A., Murphy, B. L., & Bright, D. R. pharmacy services review commissioned by NHS

13 Journal of Undergraduate Research – Volume X Working Towards a Model of Genetic Profiling for Vulnerability/Resiliency to Sleep Loss through a Summer Research Fellowship in a Military Science Laboratory By Saniya Wadhwa1,3, Michelle Chen1,3, Audrey Nikolich2,3, Ruthie Ratcliffe, MS3, and Allison Brager, PhD3 1University of Maryland College Park, 2Gettysburg College, 3Walter Reed Army Institute of Research Abstract Introduction: The following working model came from undergraduate students who participated in the Army Educational Outreach Program (AEOP). AEOP engages, inspires, and attracts the next generation of Science, Technology, Engineering, and Mathematics (STEM) talent by exposing STEM students to research conducted by the Department of Defense (DoD). Methods and Materials: The students were paired with the Sleep Research Center (SRC) – the largest research center dedicated to the impact of sleep loss on mental acuity in the DoD at the Walter Reed Army Institute of Research (WRAIR). Though WRAIR is best known for developing vaccines for infectious diseases (and carrying on the legacy of Dr. Walter Reed who discovered the vector responsible for yellow fever), groundbreaking work on the functions and substrates of sleep and how sleep enhances mental acuity was also pioneered at WRAIR. Results/Discussion: During their summer fellowship, the students were inspired by two lines of research that WRAIR has pursued. First, WRAIR has developed caffeine dosing schedules used to keep Soldiers awake during combat.2 Second, WRAIR has identified new biological targets intended to predict vulnerability/resiliency to sleep loss and subsequent impact on mental acuity. 1,2 Therefore, the students made it their goal to combine these two lines of research by developing a working model of genetic profiling that could possibly help identify Soldiers whose health and safety are at-risk during combat under compromised sleep.

Introduction countermeasures for the problem: caffeine minutes and that the mechanisms of action Identifying the problem: lack of sufficient, optimization were such that caffeine released from the restorative sleep during continuous combat Caffeine is the most consumed drug gum quickly crossed the blood-brain barrier operations in the United States. According to a study via the salivary buccal cavities, bypassing the Seven to nine hours is the gold-standard by National Institutes of Health (NIH) digestive tract.12 Second, WRAIR researchers for sleep optimization of mental acuity, researchers in which 37,602 individuals have found that the ability of caffeine to although there is inter-individual variation completed comprehensive seven-day diaries, preserve and/or slow the rate of degraded in this amount.1,2 Less than seven hours of 85% of the U.S. population consumed mental acuity with less than seven hours of sleep per night is strongly linked to lapses at least one caffeinated beverage per day.8 nighttime sleep is obsolete after three days.13 in attention, judgement, and emotional Caffeine consumption by military personnel After three days, caffeine cannot substitute reactivity. If insufficient sleep persists, both is higher than the average population and is the restorative effects of sleep for next-day morbidity and mortality increase.1,2,3,4,5,6 also the most common stimulant used by performance.13 The third and most critical Unfortunately, the United States military military personnel to stay alert and awake finding for the development of the working prides itself on achieving dominance on the in the operational environment.9 Caffeine model is WRAIR’s discovery of large inter- battlefield by means of ‘owning the night’ upregulates arousal-promoting (cholinergic) individual variation in responsivity (e.g., [see current Army Posture Statement]. Even pathways.10 Caffeine can also modestly delay tolerance and sensitivity) to caffeine’s when not operating, Soldiers have constant (also referred to as phase-shift) human sleep/ alertness and performance-enhancing effects anticipation of danger and uncertainty. These wake and endocrine rhythms.11 with sleep loss.1,2 This data is critical because factors make it nearly impossible for Soldiers The current working model was it shows that no two people respond similarly to achieve adequate and restorative sleep. built specifically on the caffeine research to sleep loss, recovery from sleep loss, or the Even for Army-employed sleep researchers completed at WRAIR. First, WRAIR ability of caffeine to mitigate the negative and physicians tasked with addressing researchers have developed caffeine dosing consequences of sleep loss. In summary, inadequate and non-restorative sleep in the schedules using a patented, quick-release these findings make up almost two decades operational environment, the fact remains caffeinated gum: Military Energy Gum of research on caffeine’s ability to stabilize that they too also suffer from the inability to (MEG).12 One piece of MEG contains 100 performance under sleep loss. These findings achieve adequate and restorative sleep during mg of caffeine. Kamimori et al. discovered in are also the basis for caffeine dosing schedules deployment for reasons listed above.7 a dose-dependent clinical trial that the gum adopted by military personnel during Identifying effective, pharmacologicalis pharmacologically active in less than 10 deployment as published in Army Training

Journal of Undergraduate Research – Volume X 14 Health Sciences

Protocol (ATP) 6-22.5: A Leader’s Guide to sleep regulation, caffeine metabolism, and morning to levels of (placebo-supplementing) to Soldier Health and Fitness (Figure 1). next-day performance: evening performance.20 Second, it has Identifying effective, biological countermeasures 1. Adenosine-derived polymorphisms been shown that early risers are more for the problem: genetic polymorphisms (ADORA2A and ADA) predict next-day physiologically and psychologically resilient The third step towards developing a performance after normal sleep and/or after to sleep deprivation.21 The particular genetic working model to optimize Soldier health sleep loss.14,15,19 The particular genetic variants of PER2 for this working model and safety was to dissect the genetic landscape variants of ADORA2A for this working model were rs2304672 and rs10462023 found of vulnerability and resiliency to sleep loss. were rs5751862, rs5760405, rs2298383, on chromosome 2. The particular genetic Select genes are involved in regulation of rs3761422, rs2236624, rs35329474, and variants of PER3 for this working model sleep amount, sleep timing, and caffeine rs4822492 found on chromosome 22. were rs35426314, rs228669, rs35733104, metabolism.14,15,16,17,18 Furthermore, the The particular genetic variants of ADA for rs228696, rs35899625, rs228697, and biochemical actions of caffeine and regulation this working model were rs73598374 and rs17031614 found on chromosome 1. For of sleepiness by adenosine are closely related. rs394105 found on chromosome 20. In these particular coding regions, previous Caffeine blocks the release of adenosine, general, these studies have found that HT4 studies have found, for example, that PER3 a neurotransmitter that suppresses neural haplotypes were more resilient to sleep loss (4/4) genotypes were more resilient to sleep activity in the brain, leading to a desire and than non-HT4 haplotypes. Interestingly, loss compared to PER3 (4/5) genotypes.19 biological need to sleep. Adenosine is also a these phenotypes were linked to “genetic Unlike research completed with adenosine byproduct of wakefulness due to increased trade-offs” such that non-HT4 haplotypes polymorphisms, the ability of caffeine production of adenosine triphosphate were more sensitive to caffeine compared to to stabilize performance in PER3 (4/5) (ATP).16,17 During sleep deprivation, HT4 haplotypes, meaning caffeine had the genotyped individuals under sleep loss is still adenosine levels in the brain will continue to ability to stabilize performance under sleep unknown. rise well beyond normal physiological ranges loss in non-HT4 haplotypes. 3. The two primary polymorphisms and will not fall until an individual sleeps.16,17 2. PER polymorphisms predict conferring inter-individual differences With this knowledge, the working preference for early rise/bedtimes (< 0500/ in caffeine metabolism, CYP1A2 and model was built on six single-nucleotide < 2100, EST) or late rise/bed times (> NAT2.22,23 The particular genetic variants polymorphisms (SNPs) underlying sleep 1000/ > 0100, EST). Preferred rise time/ of CYP1A2 for this working model were regulation by adenosine -- ADORA2A, bedtimes are important considerations. First, rs2069514, rs12720461, and rs762551 ADA -- and by circadian clock-controlled research has shown that athletes engaged found on chromosome 15. The particular genes -- PER2, PER3 -- as well as caffeine in high-risk physical activity (like Soldiers) genetic variants of NAT2 for this working metabolism at the level of the liver: CYP1A2, perform better in the evening.20 Further, model were rs1041983 and rs1801280 and NAT2.14,15,16,17,18 Each SNP has a caffeine supplementation can elevate high- found on chromosome 8. The selected selective predictive role/function pertinent risk physical activity performed in the early polymorphisms of CYP1A2 and NAT2 are linked to reduced caffeine sensitivity due to heightened metabolism of caffeine by way of heightened CYP1A2 and NAT2 ratios.22 Methods and Results Developing a working model to optimize Soldier health and safety in future studies through understanding of Soldier sleep, caffeine supplementation, and genetic variation in vulnerability/resiliency to sleep loss The working model is envisioned to be used for future WRAIR- and DoD- directed studies to assist commanders with Figure 1: Adapted from Army Training Protocol (ATP) 6-22.5: A Leader’s Guide to Soldier mission execution and used during the Health and Fitness. Table outlines caffeine dosing schedules adopted by military personnel during selection process of the Special Operations deployment. These best practices were developed from over two decades of caffeine research done at Command (e.g., Army Rangers). In order the Walter Reed Army Institute of Research (WRAIR) in Washington, D.C. for the working model to have direct military application, this would require access to an individual Soldier’s blood profile for each genetic variant of ADORA2A, ADA, PER2, PER3, CYP1A2, and NAT2. The four quadrants of the working model are founded on inter-individual variation in vulnerability/resiliency to sleep loss, caffeine sensitivity, and genetic environment (Figure 2). Cognitive performance in the model refers to the ability to maintain stable Figure 2: Intra-individual variation in the ability to perform is dependent on two principles. performance on the psychomotor vigilance The first principle is intra-individual sensitivity to sleep disruption. Some individuals, due to test, the gold-standard for assessing real-time genetic variants, are more resilient to sleep deprivation, meaning their mental acuity (tested using mental acuity (reaction time) and alertness the psychomotor vigilance test) degrades at a slower rate across sleep loss compared to individuals 1,2,12,13,14 19,23 under sleep loss. not (genetically) resilient. The second principle is intra-individual sensitivity to caffeine. In the model, A1 individuals (resilient Some individuals are highly sensitive to caffeine, allowing for performance enhancement and/or optimization under sleep loss.10,13,19 15 Journal of Undergraduate Research – Volume X Health Sciences to sleep loss and sensitive to caffeine) would focusing on genetic attributes of elite R., Hartman, T. (2014). “Beverage caffeine intake in the be the ideal candidate U.S.” Food and Chemical Toxicology. 63. Pg 136-142. to perform in military performers and/or non-performers. The 9Attipoe, S., Manganello, C., Scott, JM., Deuster, operations. According to our working working model may also help select individuals PA. (2017). “Usefulness of a risk assessment tool to risk model, these individuals may have a genetic for military service who otherwise would not stratify dietary supplements.” Military Medicine. 182. Pg predisposition that allows them to have be considered. In fact, these are the exact 2086-2091. 10Urry, E., Landolt, HP. (2015). “Adenosine, caffeine, stable performance under sleep loss coupled intents of the Defense Advanced Research and performance: from cognitive neuroscience of sleep to with possibly increased performance- and Program Agency (DARPA) program entitled sleep pharmacogenetics.” Current Topics in Behavioral alertness-enhancing benefits from caffeine. Measuring Biological Amplitude (MBA). Neuroscience. 25. Pg 331-366. These individuals would be characterized There are some limitations with the working 11Burke, TM., Markwald, PR., McHill, AW., Chinoy, ED., Snider, JA., Bessman, SC., Jung, CM., O’Neil, JS., as what military leaders would label as elite model, however. Wright, KP Jr. (2015). “Effects of caffeine on the human performers and ‘super Soldiers.’ On the First, it would require a great deal circadian clock in vivo and in vitro.” Science Translational other hand, B2 individuals (vulnerable to of knowledge and coordination to align Medicine. 305. sleep loss and tolerant to caffeine) would be work schedule/mission requirements with 12Kamimori, GH., Karyekar, CS., Otterstetter, R., least suited to perform Cox, DS., Balkin, TJ., Belenky, GL., Eddington, ND. military operations knowledge of peak optimal performance (2002). “The rate of absorption and relative bioavailability due to their possible decline in performance predicted based on the genetic variants. of caffeine administered in chewing gum versus capsules under sleep loss and an inability of caffeine Second, while optimization for when a Soldier to normal health volunteers.” International Journal of to subsequently rescue performance to pre- has to work at a sub-optimal time of the day Pharmaceutics. 234. Pg 159-167. 13Doty, TJ., So, CJ., Bergman EM., Trach, SK., sleep loss levels. Both traits of poor responses (e.g., night shift) can be achieved through Ratcliffe, RH., Yarnell, AM., Capaldi, VF 2nd., Moon, to sleep disruption and caffeine could impact caffeine supplementation, preventingJE., Balkin, TJ., Quartana, PJ. (2017). “Limited efficacy of military performance during sustained (> tolerance to caffeine would still be a concern caffeine and recovery costs during and following 5 days of chronic sleep restriction.” Sleep. 40. 24 h) missions. A2 (resilient to sleep loss but even with a genetic predisposition for caffeine 14 tolerant to caffeine) B1 (vulnerable to sleep Bodenmann, S., Hohoff, C., Freitag, C., Deckert, and sensitivity. Finally, even when controlling for J., Rétey, J.V., Bachmann, V., and Landolt, H.P. (2012). loss but sensitive to caffeine) individuals would an individual’s genetic landscape, the fact “Polymorphisms of ADORA2A modulate psychomotor be moderately suited for military operations. remains that deployed settings do not permit vigilance and the effects of caffeine on neurobehavioral A2 individuals are able to perform normally for restorative sleep and so countermeasures performance and sleep EEG after sleep deprivation.” British Journal of Pharmacology. 165. Pg 1904-1913. under sleep disruption, but caffeine such as frequent napping, early bedtimes, and 15Landolt, H.P., Rétey, J.V., and Adam, M. (2012). would not be able to give these Soldiers a absence of light/bedside technology (reduces “Reduced neurobehavioral impairment from sleep competitive edge like those who fall under the ability to achieve restorative sleep) must deprivation in older adults: contribution of adenosinergic A1. B1 individuals would hypothetically still be considered. To conclude, with greater mechanisms.” Frontiers in Neurology. 3. Pg 62-72. 16Porkka-Heiskanen, T., Strecker, R.E., Thakkar, M., be in danger with sleep disruption during knowledge of genetic profiling and benefits Bjørkum, A.A., Greene, R.W., and McCarley, R.W. (1997). military operations, but their high sensitivity of restorative sleep for performance, effective “Adenosine: a mediator of the sleep-inducing effects of to caffeine could hypothetically protect countermeasures and strategies could be prolonged wakefulness.” Science. 276. Pg 1265-1268. against decreases in military performance developed to maximize military performance. 17Porkka-Heiskanen, T. and Kalinchuk, A.V. (2011). “Adenosine, energy metabolism and sleep homeostasis.” under sustained missions. Moreover, this Sleep Medicine Reviews. 15. Pg 123-35. chart helps to classify Soldiers into different References 18 1 Viola, A.U., Archer, S.N., James, L.M., Groeger, categories of hypothetical performance, Belenky, G., Wesensten, N.J., Thorne, D.R., J.A., Lo, J.C., Skene, D.J., von Schantz, M., Dijk, D.J. contributing to the foundations for the Thomas, M.L., Sing, H.C., Redmond, D.P., Russo, (2007). “PER3 polymorphism predicts sleep structure and M.B., and Balkin, T.J. (2003) “Patterns of performance waking performance.” Current Biology. 17.7. Pg 613. development of methods to help Soldiers degradation and restoration during sleep restriction and 19Rupp, TL., Wesensten, NJ., Newman, R., Balkin, based on their genetic background. subsequent recovery: A sleep dose‐response study.” Journal TJ. (2013). “ PER3 and ADORA2A polymorphisms of Sleep Research. 12. Pg 1-12. 2 impact neurobehavioral performance during sleep Discussion Rajdev, P., Thorsley, D., Rajaraman, S., Rupp, restriction.” Journal of Sleep Research. 22. Pg 160-165. T.L., Wesensten, N.J., Balkin, T.J., Reifman, J. (2013). 20Mora-Rodriguez, R., Pallares, JG., Lopez-Guillon, There were several lessons learned “A unified mathematical model to quantify performance JM., Lopez-Samanes, A., Fernandez-Elias, VE., Ortega, JF. from the students’ research fellowships at impairment for both chronic sleep restriction and total (2015). “Improvements on neuromuscular performance WRAIR. First, the students learned about sleep deprivation.” Journal of Theoretical Biology. 331. Pg with caffeine ingestion depend on the time-of-day.” Journal 66-77. the importance of restorative vs. non- 3 of Science and Medicine in Sport. 18. Pg 338-342. Czeisler, C.A., Duffy, J.F., Shanahan, T.L., Brown, 21Garbazza, C., Benedetti, F., (2018). “Genetic restorative sleep during sustained (> 24 hour) E.N., Mitchell, J.F., Rimmer, D.W., Ronda, J.M., Silva, factors affecting seasonality, mood, and the circadian military operations. With restorative sleep, E.J., Allan, J.S., Emens, J.S., Dijk, D.J., Kronauer, R.E. clock.” Frontiers in Endocrinology (Lausanne). 9. individuals can maintain performance. With (1999). “Stability, precision, and near-24- hour period of 22Fuhr, U., Rost, KL., Engelhardt, R., Sachs, M., the human circadian pacemaker.” Science. 284. Pg 2177- Liermann, D., Belloc, C. Janezic, S., Grant, D. Meyer, UA., non-restorative sleep, performance suffers, 2171. 4 Staib, AH. (1996). “Evolution of caffeine as a test drug for compromising the health and safety of the McCauley, P., Kalachev, L.V., Mollicone, D.J., CYP1A2, NAT2, and CYP2E1 phenotyping in man by Soldiers and the unit. Second, the students Banks, S., Dinges, D.F., Van Dongen, H.P. (2013). in vivo versus vitro correlations.” Pharmacogenetics. 6. Pg learned about the ability of one’s genetic Dynamic circadian modulation in a biomathematical 159-176. model for the effects of sleep and sleep loss on waking 23Brager AJ, Ratcliffe RA, Grant D, Satterfield B, background to predict performance under neurobehavioral performance. Sleep. 36. Pg 1987-1997. 5 Capaldi V, Balkin T, Petrovick M. (2018). “0017 Genetic sleep loss that can be rescued, in part, with Killgore, W.D., Kahn-Greene, E.T., Lipizzi, E.L., polymorphisms of sleep resilency, sleep intensity, morning caffeine supplementation; some individuals Newman, R.A., Kamimori, G.H., and Balkin, T.J. (2008). preference, and caffeine sensitivity are not associated with cognitively suffer during sleep loss (the B1s “Sleep deprivation reduces perceived emotional intelligence neurobehavioral performance under repeated cycles of total and constructive thinking skills.” Sleep Medicine. 31. Pg sleep deprivation.” Sleep. 41. A7-A8. and B2s), while other individuals (the A1s 517-526. and A2s) could be cognitively preserved 6Pace-Schott, E.F., Nave, G., Morgan, A., and during sleep loss as measured from gold- Spencer, R. (2012) “Sleep‐dependent modulation of Disclaimer standard, real-time measurements of mental affectively guided decision‐making.” Journal of Sleep This summer fellowship was funded by the Army Research. 21. Pg 30-39. Outreach Education Program at the Walter Reed acuity (reaction time). 7Good, C., Brager, A., Capaldi, V., and Mysliwiec, Army Institute of Research. The views expressed in this In brief, the working model may help V. (2020) “Sleep in the United States Military.” perspective piece solely represent those of the individuals leaders take actions towards removing Neuropsychopharmacology. 45. Pg 171-191. and not the overall viewpoints of the Department of subjective bias for military selection by 8Mitchell, D., Knight, C., Hockenberry, J., Teplansky, Defense and United States Army.

Journal of Undergraduate Research – Volume X 16 A Review of Treatments of Substance Use Disorder for Transitional Age Adults By Kai Trepka, Fatima Fairfax, Jeffrey He, Eun Jae Kim, Mingu Kim, Jeongmin Lee, Rajdeep Trilokekar, and Katherine Venturo-Conerly Harvard University Abstract Mental health concerns often develop during the “transitional age” (between 18-24 years old), a time during which young adults often begin to experience the stressors and responsibilities of emerging adulthood. Yet, treatment complications and limitations that uniquely affect this age group have frequently been unaddressed, both in academia and in practice. Substance Use Disorder (SUD) is one of the most common, costly, and intractable mental health concerns that affect this demographic. Here, we perform a literature review of 35 publications and find that traditional methods of treatments such as medications, family therapies, and Cognitive Behavioral Therapy (CBT) are not only underutilized, but also poorly applied within the transitional age demographic. Emerging treatment research suggests that devising treatment plans for transitional age youth using modified traditional practices and new evidence-based practices should improve the outcomes of SUD treatments. To improve treatment efficacy and adherence, we suggest promising areas of research surrounding therapeutic alliances, community engagement, continuity, Motivational Enhancement Therapy, and Multisystemic Therapy.

Introduction that the mental health burden has been on the systems of authority in place when Prevalence and severity of mental health increasing in developed countries, specifically they were minors. This makes treatment more concerns amongst adult and adolescent upon these younger individuals. These complex, since it involves a greater circle of populations are well-established in research individuals are at elevated risk for concerns effected and influential individuals, but also and practice. The distinctions between the such as depression, anxiety, substance abuse, opens new avenues of treatment through two age groups has increasingly become a ADHD, eating disorders, PTSD, etc. Often, social systems.6 Finally, many individuals focus of mental health research, while mental the concerns increase in complexity as they with substance use disorders (SUDs) use health concerns are often overlooked in have a high rate of comorbidity.4 substances as coping mechanisms for general the gap period known as the “transitional One characteristic that influences life stressors and therefore never develop age.” Here, we define the transitional age the behavior of transitional age adults is other social and behavioral means of coping, individuals to be those between 18-24 an unstructured development period of which predisposes them to comorbid mental years of age, based on an analysis of when individuation with fewer rules, which may health disorders.7 most mental health concerns first manifest lead to increased opportunity for substance There is a decline in utilization of and the consideration by the Centers for use.4 Transitional age individuals also have mental health services as youth transition Disease Control and Prevention (CDC) and fully developed limbic systems in the brain into young adulthood. For 16 and 17-year- National Institute of Mental Health (NIMH) (which function for motivation and reward) olds, the yearly admission rate for inpatient, of an individual as a child or adolescent.1 accompanied by less developed prefrontal outpatient, and residential services in 2008 The CDC considers an individual to be an cortices (aiding in planning and inhibition), was 34 per 1000, while the number decreased adolescent until they reach age 18.2 The vast biologically predisposing them to take dramatically to just 18 per 1000 for ages 18 majority of mental health concerns develop more risks with immediate reward without and 19. Notably, among 20- and 21-year- between ages 15-24.1,3 Given these ranges, considering later consequences.5 They are also olds who utilize mental health services, more the intersection between childhood and less likely to adhere to treatment plans and to were referred from the criminal justice system mental illness’ nascent stages creates clear view their recovery as possible and essential than from family or friends.8 This shows that boundaries between adolescents, transitional since they lack (a) the level of executive there need to be more resources and support age individuals, and fully grown adults. functioning capacity that a fully developed allocated to ensure that young adult clients While research into adolescent mental health prefrontal cortex will later provide, (b) the can remain in treatment as they age out of concerns is highly specific, transitional age motivation of retaining a marriage or a full- child mental health systems. individuals often lack a clear identity in the time career, or (c) the extrinsic motivation of Furthermore, there is a median delay research lens and are grouped with one of the parentally-imposed rules. This is highlighted of 11 years between the onset of a mental other two categories. by the highly stressful environments of health concern and accessing services to Longitudinal demographic studies college, the entry to adult life, and possible correct it.3 Eisenberg et al. assert that most from 1990 to 2010 have indicated that failure to live up to social expectations.4 mental health disorders have their onset approximately one in five adolescent and Furthermore, transitional age individuals between ages 15-24, with transitional age transitional age individuals will experience are generally not vocationally established, individuals being uniquely vulnerable and mental illness.2 Overall, these studies indicate leading to a degree of continued dependence important for targeted treatments. They

17 Journal of Undergraduate Research – Volume X Social Sciences found that among college-attending students of the effectiveness of pharmacological protective effect decreased significantly as only approximately 36% of individuals who treatments. Naloxone, usually a drug individuals transitioned from adolescence screened positive for depression or anxiety prescribed to mitigate the effects of an into adulthood.14 Mean onset of SUD had accessed aid. This clearly indicates a gap overdose, can be used to overcome some in ADHD individuals occurs at 19 years that is wider among youth without access of these problems, maintaining fidelity old, which underlies the importance to the support structures postsecondary to treatment and preventing relapse.12 of factors surrounding transitional age education provides. However, Naloxone functions by inhibition (changing involvement of family, doctor, Transitional age individuals, who of pattern completion responses which are pharmacological, and other environmental experience a period of increased autonomy crucial to learning, which indicates that supports) when considering complicating and decreased regulation, are the demographic it is not necessarily a good complement to factors regarding SUD. in which substance misuse is uniquely a methadone regimen for transitional age Despite being part of an age group prevalent. Yet, traditional treatments such as individuals.12 In other words, Naloxone is with the highest level of need for mental cognitive behavioral therapy, support groups, not the best pharmacologic treatment for health services, young adults are the least and contemporary medication prescription transitional age individuals; instead, physical likely individuals to use mental health have been found to be often the least effective withdrawal symptoms should be managed be services. This demonstrates a need for for these individuals.9 Thus, it is important methadone or buprenorphine as other routes integrated treatment models that address to more completely investigate literature to of mental health treatment are pursued. the intersection of substance use and mental identify gaps in current methods of treating Many behavioral therapies exist illness. Overall, the rate of mental health substance misuse in transitional age adults. In independent of pharmacological approaches. treatment for transitional age individuals this review, we investigate the shortcomings Some evidence-based treatments include is low - only 15% of 18-25-year-olds of current treatments for transitional age contingency management therapies, receive treatment for depression, vs 38% of adults and identify promising new areas of cognitive-behavior/skills-training therapies, adolescents.15 Few studies of transitional age research as a way forward. motivational interviewing, and family individuals have examined differing effects of Methods treatments.9 Contingency management mental health treatment between transitional Research papers on substance use therapies motivate patients to perform age socioeconomic and ethnic subgroups. disorders in transitional age adults were desired actions, such as passing a drug Although young adults have an overall higher identified from an electronic database by test, by providing systemic rewards. Such a prevalence of and lower treatment of alcohol using search terms to specify relevant articles. method has shown promise, but it ideally and serious psychological distress, males (as Using PubMed and Google Scholar (January requires more outreach to policymakers opposed to females) and non-Whites (as 2000 to April 2017), combinations of the and the general legal framework. Skills- opposed to Caucasians) both proportionally search terms transitional age, adolescent, training therapies have strong empirical receive less treatment, even after accounting substance use disorder, substance abuse, backing in other mental health treatments, for economic and insurance disparities. adolescent, and mental health were such as depression or anxiety, but there This suggests that stigma and personal/ necessitated. For the purpose of this review, has been less study as to their limitations. cultural factors play a large role, potentially “transitional age” individuals are individuals Motivational interviewing, which entails having negative effects on treatment fidelity. between 18 and 24 years of age. Research guided conversation meant to increase Surprisingly, income plays little role in the papers focused on primarily non-transitional intrinsic motivation and aid application of rate of treatment, perhaps because these age individuals (i.e. individuals outside the said motivation, has been shown to generally individuals still have access to their parents’ age range of 18-24) were excluded. Of the increase fidelity to treatments as it creates resources. remaining accessible articles, case studies an overall more positive attitude towards Race influences current treatment and articles where mental health, non- treatment, thus staving off relapse, but has availability and fidelity. Employing a transitional age individuals, or substance use not been shown to be as effective on its targeting strategy driven by race may be were not central were excluded. Articles used own. Family treatments have shown greater beneficial.16 Cost and stigma were the most in this review only had human subjects and efficacy on their own, but their main impact significant barriers to receiving mental were written in English. has also been shown to lie in fidelity, with the health care, and transitional age individuals Results added effect of improving the mental health are particularly susceptible to believing and Traditional Methods state of peripheral individuals impacted by being negatively affected by negative stigmas Because of the high risks of substance the disorder. surrounding mental health. For example, an misuse and its corresponding impacts in Other studies have investigated the individual whose cultural background and young adults, improved SUD treatment availability and use of mental health services home environment both stigmatize mental for this age group is important. SUDs are for concurrent disorders amongst transitional health disorders and/or addiction is less not only most prevalent in the transitional age individuals.13 It was shown that 65% of likely to seek treatment. Additionally, the age group, but also many treatments that the participants in their study with substance study suggests that there exists a significant are effective for adults and adolescents have use disorders have at least one lifetime mental correlation between people who perceive that been found to have severe shortcomings in disorder. One such example where treatment they need mental health treatment services treating this specific population.10 of a concurrent mental health disorder but fail to receive them and people with There are two prevalent pharmacological affected SUD risk can be found in the substance use disorder (SUD). We believe methods for the treatment of SUDs. As of complex relationship between medication that further studies are necessary to validate 2009, most drugs to treat addiction are for Attention Deficit Hyperactivity Disorder this claim. opioid agonists that eliminate withdrawal (ADHD) and the risk of substance misuse. Education also affects incidence and symptoms; the most commonly used Wilens et al. (2013) found in a meta-analysis treatment. Education attainment and school drugs of this class are methadone and of six studies that while pharmacological enrollment are protective factors as substance buprenorphine.11 Post-treatment fidelity treatment decreased the risk in children with misuse is less compatible with college student (continued sobriety) is the primary concern ADHD for later substance use disorder, this lifestyles.17 Treatment fidelity was higher

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for college students. These students were Modifications transition protocols for patients with mental more likely to complete substance misuse Engagement between counselors and disorders who need to continue care into treatment than non-students and completed patients should be increased where feasible. adult mental service. Currently, there is no it in a faster timeframe. Students were most Therapeutic alliances between counselors consensus on what constitutes as a successful likely to misuse alcohol and marijuana as and young adult patients play an important transition. Moreover, there is a decline in the they can remain relatively high functioning role in dealing with substance misuse.23 A use of mental health services by transitional under these substances, while non-students therapeutic alliance exists when “the therapy age youth as they transition from adolescence delved into other drugs. dyad is engaged in collaborative, purposeful to adulthood, even in the case of continuing It is unclear what effect regional work”.24 A therapeutic alliance emphasizes disorders. differences have on substance misuse the participation of both counselors and Varying the location of treatment alters treatment. In literature prior to 2008, many their patients in creating goals and therapy its effectiveness, particularly for young adults studies showed that substance misuse was less tasks, fostering an emotional bond between receiving substance use treatment who also common in rural areas in the US.18,19 However, patients and their therapists. The strength have co-occurring psychiatric disorders.9 a study from 2015 suggests that substance of the counselor patient alliance correlated People with co-occurring disorders (COD) misuse is higher in rural areas, especially with significantly with positive treatmentwere seen to put strain on coping resources, alcohol and methamphetamine.19 In order outcomes in patients. Patients who began which resulted in poorer treatment response to help youth in rural areas, intervention treatment with higher levels of motivation and outcomes. COD patients reported higher programs taking into consideration the rural and self-efficacy to abstain from substances level of dependence severity and substance context and the existing rural infrastructure showed stronger therapeutic alliances. use consequences. For treatment, they need to be developed. Problems of mandated and resistant clients reported that treatment delivered in familiar, After the initial administration of will still exist in many cases; however, a residential settings could most benefit COD treatment, close monitoring of potential starting point of dyadic therapy (i.e. using patients, as it alleviates some psychological for relapse is important. Two-thirds of the the patient’s goals to guide a treatment plan) stress by reducing environmental demand participants in the study had relapsed to drug will likely improve care. and providing a consistent emotional support use within six months.20 While rates of relapse Likewise, active participation of system. Dedication to substance abstinence following treatment are comparably high in transitional age patients in making decisions resulted in greater availability of cognitive both adults and adolescents, the reasons for on what medications to take leads to reduced resources and interventions were maximized relapse differ significantly. Adults relapsed in symptoms, higher self-esteem, and improved by addressing motivation, self-efficacy and social situations in which they experienced fidelity.25 Conversely, top-down prescriptions coping skills. The study was consistent with urges and temptations to drink/use or when result in the overuse of psychotropic drugs, other articles showing that young adults are they were trying to cope with a negative which have unique and negative side effects very susceptible to co-occurring disorders, emotion and urges and temptations to drink/ during the transitional age. The support of and that patients with COD need specialized use. In contrast, nearly 70% of adolescent advocates such as mental health providers treatment for their health. subjects reported that they relapsed in during meetings with psychiatrists can Increasing focus on Motivational social situations when they were trying to improve deliberation, as can psychiatrists Enhancement Therapy (MET) could be enhance a positive emotional state.21 Given who are available outside of office time to potentially effective for this age group. that young adults are often in environments provide quick answers to concerns about MET is a technique that relies on inducing where substance misuse is not only tolerated dosage and about side effects. rapid and internally motivated change, but even glorified, there need to be programs Community engagement and external often causing individuals to overcome their that rigorously follow up with young people focus are beneficial in avoiding and opposition to engaging in treatments for recovering from substance misuse. alleviating substance use and other forms substance misuse.30 Tobacco addiction almost Finally, there are various public of mental illness.26 Interestingly, Hispanic always begins between the ages of 18 and 24 strategies that synthesize psychological teens who feel more responsible for others and complicates mental health treatment by and pharmacological approaches and are (such as their family) are less likely to binge increasing the metabolism of antipsychotic currently employed by substance misuse drink and smoke marijuana than teens who and antidepressant medications. Of treatment services to help adolescents see emerging adulthood as a time for self- psychiatric patients, 50% with anxiety and their families: pairing families with exploration or who feel less of an obligation and 66% with depression smoke. Parents professionals, organizing programs to gather to others.26 Mentally ill teens also expressed are a factor which enables smoking, both families together, and enlisting policy makers much greater life satisfaction if they were by purchasing cigarettes, providing a role to help make decisions for families through engaged in work which they thought might model who smokes, and not discouraging having access to experts.22 In other words, benefit others and if they felt that they had tobacco use, especially within certain cultural the first technique is an approach to help one meaningful social connections. This sense groups. Additionally, although mental health particular family while the second groups of belonging and usefulness is essential for providers and youth agree that smoking is a families together to create a self-supporting mental health and healthy behaviors and way for subjects to engage with their peers, it community. The latter technique can have can improve treatment effectiveness, though is also an addictive and unhealthy behavior, long-term effects in multiple families, which its effects may vary widely between different and providers and youths often propose was the case in states such as Wisconsin ethnic and social groups.27,28 different solutions to addiction. Youth where the Child and Youth Substance Abuse Continuity of treatment from often prefer to quit “cold turkey” and avoid Subcommittee was installed to aid families in adolescence into adulthood is important. pharmacologic treatments, whereas providers getting the right substance misuse treatment More longitudinal, controlled health services either view smoking as an inevitable “fact the victim needs. However, even with these research must be conducted to find optimal of life” or prioritize the use of cessation different techniques being employed through service models of treatment for those in the medication like nicotine patches. However, more than nine states, the issues of substance transitional age period.29 More specifically, “motivational strategies” were recommended misuse and recovery persist. there needs to be systematic and seamless by both youth and providers, potentially

19 Journal of Undergraduate Research – Volume X Social Sciences an avenue for compromise. Mental health likely to commit property crimes. This, along a strong metric by which we can evaluate facilities are also viewed by both providers with a lack of significant results in terms of current and potential treatment avenues. and youth as a safe space to talk about these improving psychiatric well-being, indicates Traditional methods such as problems and are another potential way to that MST is likely to be only useful as a pharmacological regimes and late- address addiction.31 complement as long as the underlying issues stage contingency management are Similarly, there is often an escalation of are treated. relatively ineffective in terms of treatment drinking and alcohol use problems in the To further accentuate this nuanced fidelity. Family treatments, motivational transitional age group.32 Despite high rates point of view, though, the efficacy of MST is interviewing, and CBT are underutilized of alcohol usage, only a small proportion also sensitive to cultural needs and is suitable and do not account for relapse. As a result, of people seek and receive treatment. for a diverse range of ethnic groups.35 This current treatment overall is underutilized Furthermore, canonical interventions fail complements the fact that in the previous and results in racial and socioeconomic for older adolescents. Late adolescence is a study 60% of the patients were African discrepancies. period of high vulnerability as there are vast American. The only major racial factor Instead, treatments should be modified to “neurologic, cognitive, and social changes” that had an impact was that race matching focus more on creating therapeutic alliances, that occur. Hence, treatment should between therapist and patient was beneficial. engaging patients with the community and capitalize on “transient high motivational Rowe et al’s work validated the persistent youth, continuing treatment from youth to states of youths” who, at a younger age, have efficacy of MST for up to 14 years.35 adulthood, deciding the most appropriate fewer drug use problems that might arise This is because, most importantly, physical location of treatment, increasing from alcohol and are more likely to want to MST’s effects are persistent over many years. focus on MET and CBT (perhaps as an change their drinking habits. “Motivational Thus, combining MST with other treatment integrated therapy), and using multisystemic enhancement techniques” (such as MET) forms can ensure fidelity to treatment and therapy to supplement other treatments. should be considered as an early treatment. preventing relapses.12 The patients in the Overall, we found a lack of research on Integrating multiple therapies is a Henggeler study had low treatment fidelity to treatment specific to the period of transition potentially effective technique. For example, the MST, but that could be explained by the from youth to adulthood. Where research Hersh et al (2013) investigated a combination lack of treatment for the underlying factors.35 was present, it was often solely correlational, of Cognitive Behavioral Therapy (CBT) Thus, MST is undeniably beneficial, but and the sample size rarely exceeded a few and MET.33 Few studies have investigated only truly makes an impact in the context of dozen people. Even though the intent of the how depression and conduct disorder affect a larger treatment plan. research was to improve treatment and clinical efficacy of substance misuse treatment in Discussion and Conclusions outcomes, it often lacked essential features to transitional age individuals – prior research In this paper, we report that the verify its efficacy, such as clinical trials with a focused on depression and conduct disorders transitional age demographic is socially control group. Finally, the methods that were individually, instead of treating them as and physiologically distinct from both proposed are not implemented widely by an integrated, unique problem. Cognitive adolescents and adults. Usually, when a large psychiatrists today. More clinical research is behavioral therapy that addresses youths’ age demographic with a disorder exists, an needed on the transitional age demographic hostile attribution bias and builds social outline for treatment rapidly emerges, as it to understand why certain treatments are support combined with motivational did for adults and adolescents with mental ineffective and which modifications should enhancement therapy to increase goal health disorders. Despite the large size of be made. setting proved effective, even with only four the transitional age demographic and the An essential limitation of our review sessions over a year. However, this study propensity of mental health and substance paper is that in our discussion of transitional lacked a control group and focused mostly misuse disorders to arise during this time, age individuals, we lack substantial overview on Caucasians. Interestingly, contrary to there is still no unified framework to treat of the effects of childhood and adolescence previous studies, stronger depression makes transitional age individuals. Treatments for on the lives, habits, and personalities of substance misuse treatment more effective, co-occurring substance misuse and mental those in the transitional age. As a result, implying both that more research needs to be health disorders need to account for their we cannot adequately capture the potential done on the way mental health disorders can uniqueness. importance of mitigating risk factors for affect substance misuse treatment and that To prevent disorders, therapists should SUD that present themselves in childhood one must consider the length of treatment screen clients for different SUDs since and adolescence. If we take this logic to and follow up when comparing different young adults don’t always recognize the its conclusion, substantive treatment for studies. Higher income is also correlated with importance of treating their disorders transitional age individuals is potentially of better treatment outcomes, possibly because early.32 In treatment, therapists should adopt a lower priority as deeper knowledge and wealthier youths have more opportunities a fluid, patient-centered approach, use preventative treatment rooted in childhood to remove themselves from negative peer developmentally tailored communication and adolescence could prevent both SUD associations. and engagement, involve and train parents if and associated concerns. Multisystemic Therapy (MST), a possible, and help patients to develop a non- However, this logic is predicated upon specific family-involved therapy, has some using support network. Finally, therapists further research in transitional ages that is significant benefits down the line, but is should emphasize treatment engagement not currently showcased in literature. This not universally helpful on its own.34 Firstly, rather than full adherence, as young adults reinforces the importance of our thesis it indicates that there is a disaggregation of often relapse at first and cannot immediately calling for further research. Further research, antisocial tendencies where the problems reach recovery. Successful recovery in which our paper could not capture, could associated with the drug misuse, namely transitional age individuals should not encapsulate dichotomies between university- crime, are transitioned from an “overt” be defined as immediate, uninterrupted attending individuals, vocational individuals, setting to a “covert” setting. That is to say, sobriety, but instead as a continued or unemployed individuals. It could also the patients who go through MST are less dedication to treatment and desire to become include longitudinal studies and treatment likely to commit aggressive crime, but no less sober, healthy, and productive. This provides pipelines which have yet to be

Journal of Undergraduate Research – Volume X 20 Social Sciences publicized (clinical/lab phases) and were this critical issue. (e.g. alcohol vs marijuana). While this review thus not expressed in this paper. To address While it is the outside the scope of primarily focuses on unifying factors that this concern, we searched the intellectual our paper, it may be important as well to impact both alcohol and marijuana use property database Innography twice, once consider experiences and treatments provided disorders in transitional age adults, research for “substance use mental health” and once during childhood and adolescence for these and treatment must also take into account for “substance use disorders addiction transitional age individuals, as problems the particular substance being abused. treatment” (Figure 1). Both showed similar during transitional age may more commonly Thus, we recommend future research trends in both patents filed and grants stem from previous experiences. This, if should be conducted with longitudinal given; the latter showed significantly greater found to be true, would suggest that efforts studies following a large population of youth amounts of data and is displayed below. The focused on preventative care during earlier that finds correlations between factors in number of grants offered spiked in 2012 years would be better served than those childhood and transitional age substance and has steadily declined since. Overall, focused on treatments targeting transitional misuse disorders. A correlational study with filings follow grants with a one- to two-year age individuals. a large sample size would greatly add to our delay, and the four-year decline since 2012 Even after this review of multiple studies understanding of the cause for these disorders, in both grants and patents indicates that the on substance misuse of individuals who are and a greater emphasis on prevention can be field is “drying up” and needs revitalization. in the transitional age group, there are still made, rather than treatment. In addition, This positions research into transitional age many questions left unanswered. A major transitional age individuals are admitted for individuals as a uniquely important avenue issue includes the multitude of factors that mental health treatment at extremely lower of research. Findings in this specific avenue may take role in an adolescent’s decision. rates; more research is needed to explain of research could stimulate the idle academic Transitional age has proven to be a particular these low admission rates. More information status quo. Given the established lack of age group that can be found to be committing addressing the factors of deterrence that substantial information, which led to the detrimental behaviors such as substance most transitional age individuals face when limitations we highlighted in our review, a misuse. However, the elements in the considering mental health treatments can stimulus could lead to new developments adolescent’s environment that can elicit such help health care workers propose more in addiction and mental health treatment behaviors are yet to be determined, whether effective plans that would benefit all potential beyond the narrow scope of transitional these elements depend on ethnic culture, treatment options. Finally, clinical trials with age individuals and shed new light on our gender, geography, or race just to name a few. the treatments listed in our results section understanding of comprehensive prevention Additionally, part of the difficulty individuals would allow a robust evaluation of each and treatment methodologies. of transitional age encounter in coping with treatment option. Further, our analysis of the primary issues such as substance misuse include References studies in that the range of age group their lack of utilization of existing mental 1[N.A.] (2020) “Child and adolescent mental health.” National Institute of Mental Health. National identified as transitional youth varied health services. What specifically yields Institutes of Health. (Accessed 02/05/2020) selection of studies. There is a need for more many similarities in the social and molecular 2Perou, R., Bitsko, R. H., Blumberg, S. J., Pastor, P., Ghandour, R. M., Gfroerer, J. C., Hedden, S.L., research on transitional age individuals and mechanisms contributing to substance Crosby, A.E., Visser, S.N., Schieve, L.A., Parks, S.E., their relationship with substance use in misuse, important differences in the research, Hall, J.E., Brody, D., Simile, C.M., Thompson, W.W., general, and we hope that currently ongoing treatment, and legal environments exist Baio, J., Avenevoli, S., Kogan, M.D. and Huang, L.N. longitudinal studies can shed new light on depending on the substance being misused (2013) “Mental health surveillance among children— United States, 2005–2011.” Morbidity and Mortality Weekly Report 62. Pg 1-35. 3Eisenberg, D., Golberstein, E. and Gollust, S. (2007) “Help-seeking and access to mental health care in a university student population.” Medical Care 45(7). Pg 594-601. 4Mandarino, K. (2014). “Transitional-age youths: Barriers to accessing adult mental health services and the changing definition of adolescence.” Journal of Human Behavior in the Social Environment 24(4). Pg 462-474. 5Chung, W. W. and Hudziak, J. J. (2017) “The transitional age brain: the best of times and the worst of times.” Child and Adolescent Psychiatric Clinics 26(2). Pg 157-175. 6Kim, H., Munson, M. R. and McKay, M. M. (2012) “Engagement in mental health treatment among adolescents and young adults: a systematic review.” Child and Adolescent Social Work Journal 29(3). Pg 241-266. 7Hartz, S. M., Pato, C. N., Medeiros, H., Cavazos- Rehg, P., Sobell, J. L., Knowles, J. A., Bierut, L.J. and Pato, M. T. (2014) “Comorbidity of severe psychotic disorders with measures of substance use.” Journal of the American Medical Association Psychiatry 71(3). Pg 248-254. 8Pottick, K.J., Bilder, S., Vander Stoep, A. et al. (2007) “US patterns of mental health service utilization for transition-age youth and young adults.” The Journal Figure 1: Substance Use Disorder Patent Applications. Global patent applications for “substance of Behavioral Health Services and Research 35. Pg 373- use disorders addiction treatment” from 1995 to 2015. Since 2012, there has been a steady 389. downward trend, suggesting a need for revitalization of funding SUD research. 9Carroll, K. M. and Onken, L. S. (2005)

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“Behavioral therapies for drug abuse.” American Journal adult clients.” Journal of Behavioral Health Services and of Psychiatry 162(8). Pg 1452-1460. Research 42(2). Pg 238-253. 10Bergman, B. G., Greene, M. C., Slaymaker, V., 26Allem, J. P., Lisha, N. E., Soto, D. W., Baezconde- Hoeppner, B. B. and Kelly, J. F. (2014) “Young adults Garbanati, L. and Unger, J. B. (2013) “Emerging with co-occurring disorders: substance use disorder adulthood themes, role transitions and substance use treatment response and outcomes.” Journal of Substance among Hispanics in Southern California.” Addictive Abuse Treatment, 46(4). Pg 420-428. behaviors 38(12). Pg 2797-2800. 11[N.A.] (2009) “Guidelines for the 27Resnicow, K., Soler, R., Braithwaite, R. L., psychosocially assisted pharmacological treatment Ahluwalia, J. S. and Butler, J. (2000). “Cultural of opioid dependence.” World Health Organization. sensitivity in substance use prevention.” Journal of (Accessed 28Unger, J. B. (2015). “Preventing substance 02/05/2020) use and misuse among racial and ethnic minority 12Kesner, R. P., Kirk, R. A., Clark, J. K., Moore, adolescents: Why are we not addressing discrimination A. and Keefe, K. (2016) “Naloxone injections into CA3 in prevention programs?” Substance Use and Misuse disrupt pattern completion associated with relapse from 50(8-9). Pg 952-955. cocaine seeking.” Hippocampus 26(7). Pg 892-898. 29Reale, L. and Bonati, M. (2015). “Mental 13Miller, S., Ringeisen, H., Munoz, B., Hedden, S., disorders and transition to adult mental health services: Colpe, L., Rohloff H. and Embry, V. (2016) “Correlates A scoping review.” European Psychiatry 30(8). Pg 932- of mental health services use among young adults with 942. mental illness: results from the National Survey on Drug 30Tevyaw, T. O. L. and Monti, P. M. (2004). Use and Health.” Psychiatric Services, 67(6). Pg 642- “Motivational enhancement and other brief 649. interventions for adolescent substance abuse: 14Wilens, T. E., Faraone, S. V., Biederman, J. foundations, applications and evaluations.” Addiction and Gunawardene, S. (2003) “Does stimulant therapy 99. Pg 63-75. of attention-deficit/hyperactivity disorder beget 31Prochaska, J., Fromont, S., Wa, C., Matlow, later substance abuse? A meta-analytic review of the R., Ramo, D. and Hall, S. (2013) “Tobacco use and literature.” Pediatrics 111(1). Pg 179-185. its treatment among young people in mental health 15Adams, S., Knopf, D. and Park, M. J. (2014) settings: A qualitative analysis.” Nicotine and Tobacco “Prevalence and treatment of mental health and Research 15(8). Pg 1427-1435. substance use problems in the early emerging adult years 32Brown, S. A., McGue, M., Maggs, J., in the United States: Findings from the 2010 National Schulenberg, J., Hingson, R., Swartzwelder, S., Martin, Survey on Drug Use and Health.” Emerging Adulthood C., Chung, T., Tapert, S.F., Sher, K., Winters, K.C., 2(3). Pg 163-172. Lowman, C., and Murphy, S. (2008) “A developmental 16Mason, M.J., Keysey-Marcus, L., Snipes, D., perspective on alcohol and youths 16 to 20 years of age.” Benotsch, E. and Sood, B. (2013) “Perceived mental Pediatrics 121. Pg S290-S310. health treatment need and substance use correlates 33Hersh, J., Curry, J. and Becker, S. (2013) “The among young adults.” Psychiatric Services 64(9). Pg influence of comorbid depression and conduct disorder 871-877. on MET/CBT treatment outcome for adolescent 17Sahker, E., Acion, L. and Arndt, S. (2015) substance use disorder.” International Journal of “National analysis of differences among substance abuse Cognitive Therapy 6(4), Pg 325-341. treatment outcomes: College student and nonstudent 34Henggeler, S. W., Clingempeel, W. G., Brondino, emerging adults.” Journal of American College Health M. J. and Pickrel, S. G. (2002) “Four-year follow-up 63(2). Pg 118-124. of multisystemic therapy with substance-abusing and 18Borders, T. F. and Booth, B. M. (2007). substance-dependent juvenile offenders.” Journal of the “Rural, suburban, and urban variations in alcohol American Academy of Child and Adolescent Psychiatry consumption in the United States: Findings from the 41(7). Pg 868-874. National Epidemiologic Survey on Alcohol and Related 35Rowe, C. L. (2012) “Family therapy for drug Conditions.” The Journal of Rural Health 23(4). Pg abuse: Review and updates 2003–2010.” Journal of 314-321. Marital and Family Therapy 38(1). Pg 59-81. 19Lambert, D., Gale, J. A. and Hartley, D. (2008) “Substance abuse by youth and young adults in rural America.” The Journal of Rural Health 24(3). Pg 221- 228. 20Cornelius J.R., Maisto S.A., Pollock N.K., Martin C.S., Salloum I.M. and Lynch K.G. (2001) “Rapid relapse generally follows treatment for substance use disorders among adolescents.” Addictive Behaviors 27. Pg 1-6. 21Ramo, D. E. and Brown, S. A. (2008) “Classes of substance abuse relapse situations: A comparison of adolescents and adults.” Psychology of Addictive Behaviors 22(3). Pg 372-379. 22Mcgillicuddy, and Eliseo-Arras. (2012) “Parent–adolescent report correspondence on adolescent substance abuse among teens in residential rehabilitation.” Addictive Behaviors 37(4). Pg 456-462. 23Urbanoski, K. A., Kelly, J. F., Hoeppner, B. B. and Slaymaker, V. (2012) “The role of therapeutic alliance in substance use disorder treatment for young adults.” Journal of Substance Abuse Treatment 43(3). Pg 344-351. 24Hatcher, R. L. and Barends, A. W. (2006) “How a return to theory could help alliance research.” Psychotherapy: Theory, research, practice, training 43(3). 292-299. 25Delman, J., Clark, J., Eisen, S. and Parker, V. (2015) “Facilitators and barriers to the active participation of clients with serious mental illnesses in medication decision making: The perceptions of young

Journal of Undergraduate Research – Volume X 22 Understanding Benthic Macroinvertebrate Communities in Beaver Meadows of Rocky Mountain National Park By Valerie T. Doebley Colorado State University Abstract In mountain regions, river-floodplain meadows can develop in unconfined valley sections of the river network. River-floodplain meadows are ecologically significant regions due to their ability to retain carbon and nutrients through several processes, including the storage of large woody debris and the accumulation of particulate and dissolved organic carbon in the sediment during flood events. These processes are influenced by the historic land use, such as livestock grazing or farming, and the presence of beavers in the meadow. Past projects in Rocky Mountain National Park examined the physiochemical and hydrologic characteristics of river-floodplain meadows with current or past beaver activity. However, past studies did not look at the communities of aquatic organisms residing in these areas.1,2 Aquatic macroinvertebrates are an effective biological indicator that are used to examine the effects of anthropogenic impacts on lotic ecosystems. The purpose of this study is to examine the aquatic macroinvertebrate communities at the inflows and outflow of six beaver meadows of Rocky Mountain National Park. By studying the aquatic insect communities at both ends of active and abandoned beaver meadows, this project examines: 1.) How the location above or below a meadow impacts communities, by comparing community composition at the outflows to inflows of meadows; 2.) any non-location- specific impact of beaver activity by comparing active and abandoned meadow communities, and, 3.) the interaction between location and beaver activity, in other words, a comparison of the change between inflow and outflow communities in active versus abandoned meadows. There were significant differences in several taxa between inflows and outflows of meadows, suggesting that meadows do impact the downstream communities. There were also more families that displayed overall higher abundances in active than abandoned meadows, regardless of inflow or outflow location. There were also two families, Glossosomatidae and Leptophlebiidae, which displayed an interaction effect such that their abundance significantly increased between the inflow and outflow of active meadows, but not of abandoned meadows.

Introduction such as benthic macroinvertebrates. and fine particulate organic matter (FPOM) River-floodplain meadows in unconfined Examining the macroinvertebrate as food, it is possible that a meadow’s effect valley sections of mountain stream systems communities of streams is commonly used to on the particulate organic carbon in a stream are an important sink in the carbon cycle.1 biomonitor how humans impact stream health is a mechanism impacting downstream These areas are often impacted by human and water quality.3 A healthy stream is capable macroinvertebrate community composition.5 land-use practices, which can alter the natural of supporting a diverse macroinvertebrate The purpose of this study is to use benthic dynamics of the river and meadow. The community with a variety of life history traits macroinvertebrate communities as a lens to presence or absence of beavers is an important and feeding habits. Accordingly, abundance examine the differences between the quality characteristic of river-floodplain meadows and diversity of macroinvertebrate taxa are of streams at the inflows and outflows of six that is impacted by past and current land-use biological indicators of stream ecosystem river-floodplain meadows in Rocky Mountain practices. Beaver activity is associated with health. Comparing the macroinvertebrate National Park (RMNP). Based on past increased geomorphic complexity, carbon communities of beaver-less meadows with studies on the physiochemical and hydrologic retention, and aquatic ecosystem metabolism.2 more intense land-use histories to less properties of river-floodplain meadows1,2, Another study found that the river-floodplain impacted active beaver meadows can indicate I hypothesized that macroinvertebrate meadows with beaver activity are particularly how human activities affect stream quality in abundance and diversity would be greatest at effective at retaining and processing carbon meadows. the outflows of active beaver meadows. The six due to several natural processes occurring in Furthermore, a stream’s characteristics meadows in this study were selected because these meadows. These processes include the impact the macroinvertebrate community they have different land-use histories and storage of large woody debris and the capture composition due to the various habitat consequently they have different levels of beaver of dissolved and particulate organic carbon needs and trophic relations of different taxa.4 activity and geomorphic complexity. These into sediments during flooding in unconfined The functional feeding groups of the taxa meadows were also selected because previous sections.1 The increased geomorphicfound in a stream can provide insight to the studies through Colorado State University’s complexity, aquatic ecosystem metabolism, stream’s ecosystem and water quality. Since Natural Resource Ecology Laboratory and carbon retention in beaver meadows may feeding groups such as shredders, collector- already examined their physiochemical and impact downstream habitat and community filterers, and collector-gatherers rely on hydrologic characteristics.1,2 By examining composition of biological indicator organisms coarse particulate organic matter (CPOM) these meadows at both inflows and outflows,

23 Journal of Undergraduate Research – Volume X Natural Sciences it can be determined if processes occurring so that the contents of the plot flowed into the small number of sites, especially in cases where within these meadows are impacting the net, and 3) any remaining sand, gravel, plants, there is a strong and consistent relationship downstream macroinvertebrate communities. or small rocks within the plot were stirred by between abundance and site category. Furthermore, comparing the differences hand. For these analyses, the insects were between inflows and outflows across active After the entire contents of the plot grouped by order, family, or functional and abandoned beaver meadows can provide were thoroughly scrubbed and stirred up, the feeding group (Table 3). Functional feeding insight to the effects of current beaver activity Surber sampler was removed from the water. groups were determined using information and channel complexity on ecosystem and The sample was deposited into a five-gallon provided in “The Aquatic Insects of North habitat quality. bucket of water by turning the net of the America”.6 All abundance values were Surber sampler inside out and dipping it into logarithmically transformed by taking the Methods the bucket. The contents of the bucket were natural log of the abundance plus one. A conceptual diagram outlining the then poured through a 600-micron sieve and Logarithmic transformations are a common research process for this study is in Table 1. transferred into a 1 L plastic jar. The Surber way to account for the issue that benthic Study Location sampler, bucket, and sieve were inspected for macroinvertebrate datasets are usually not Benthic macroinvertebrate sampling was any remaining macroinvertebrates, which normally distributed and do not meet the performed at two places on six meadows in were transferred into the jar using forceps. assumptions of parametric statistical methods Rocky Mountain National Park, for a total of Samples were preserved in a 95% ethanol (e.g., homogeneity of variance).7 12 sampling locations. These meadows were solution. Although lower concentrations of divided by activity level into two categories: ethanol are adequate to preserve samples, 95% Results active meadows and abandoned meadows. ethanol is used in the field because a small Total macroinvertebrate abundances were Active meadows have current beaver activity amount of water from the stream ends up the variable between locations, meadows, and in and included Mill Creek and Glacier Creek. jar, diluting the ethanol’s concentration. Once some cases between replicates, with densities Abandoned meadows no longer have any in the laboratory, individual specimens from ranging from 12 to over 600 specimens per beaver activity and included Moraine Park, the sample can be safely transferred into new Surber sample. The average abundance of Upper Beaver Meadows, Hidden Valley and vials containing an 80% ethanol solution. macroinvertebrates per Surber sample in active Cow Creek. All of the abandoned meadows Laboratory Methods meadows was 94 specimens at inflow sites and had historic beaver activity and still share In the laboratory, all macroinvertebrates 197 specimens at outflow sites. In abandoned varying characteristics of active meadows, were removed from the sample jars containing meadows on average there was 111 specimens such as slowed movement of water. 95% ethanol, sorted, and placed into new, at inflows and 110 specimens at outflows Each meadow was sampled at two separate vials containing 80% ethanol. Other (Figure 3). The number of families of aquatic locations: an inflow location upstream of the organic materials from the sample were also insects per sample was also examined. Active meadow and an outflow location downstream preserved. All macroinvertebrates from the meadows averaged 9.0 families at inflows from the meadow (Figure 1). Each meadow samples were sorted by taxa using a dissection and 9.9 families at outflows. Abandoned has one inflow and one outflow. Active microscope. Aquatic insect larvae from the meadows averaged 8.9 families at inflows and meadow sampling locations are referred samples were sorted by family. Pupas found 9.1 families at outflows Figure( 4). Neither to as “active inflow” and “active outflow”. in the samples were sorted by order. Some total abundance nor number of families per Abandoned meadow sampling locations samples also included some organisms other Surber sample was found to be statistically are referred to as “abandoned inflow” and than aquatic insects. These included Bivalves, significantly different between inflows and “abandoned outflow”. Classifications of the Trombidiformes (water mites), Gastropods, outflows or across activity levels. six meadows are shown in Table 2. Aquatic Annelids, Collembola, and terrestrial insects. Macroinvertebrate samples contained macroinvertebrates were sampled at both Data Analysis aquatic insect larvae from five orders: inflow and outflow of each meadow to help Data analysis was performed using Ephemeroptera (mayflies), Plecoptera determine if processes occurring within a R-studio. A series of one-way and two-way (stoneflies), Trichoptera (caddisflies), Diptera meadow result in differences between the ANOVAs were run to compare the abundance (true flies), and Coleoptera (beetles). These macroinvertebrate communities upstream of different taxa across different site categories: orders are divided into families. The raw data and downstream of the meadow. The final active vs abandoned meadows, inflow vs by orders and families can be found in table 4. study design consisted of two active and four outflow locations, or an interaction (activity Three of the aquatic insect orders, Plecoptera, abandoned meadows, each with an inflow and level x location), using an alpha-value of Ephemeroptera, and Coleoptera, were overall outflow sampling location Figure( 2). 0.1. P-values of less than 0.1 indicate that more abundant in active meadows than Field Methods the difference in abundance between site abandoned meadows, regardless of the location Benthic macroinvertebrate sampling was categories is significantly significant. A p-value on the meadow (p-values = 0.063, 0.0608, performed using a 500-micron Surber sampler greater than 0.1 indicates that there is no and 0.00364, respectively). No orders showed and a 600-micron sieve. At each sampling significant difference in abundance between significant differences between inflow and location, Surber samples were collected in site categories. No significant difference could outflow abundances or an interaction effect riffles or runs no deeper than knee height. mean: 1.) the site category does not impact between activity level and location. Although Four replicates were taken at four suitable the abundance, or 2.) there was not enough most of the organisms collected were aquatic riffles or runs positioned closest to the stream data collected to find an impact on abundance insects, some samples also contained Bivalves, gauging station at each location. Replicates statistically significant. For this study, four Trombidiformes (water mites), Gastropods, were taken moving from downstream to replicate samples were taken at 12 sites, Annelids, Collembola, and terrestrial insects. upstream to avoid disturbing subsequent categorized into two activity levels and two The aquatic insect larvae found in these replicates. At each selected riffle or run: 1) the locations. While a greater number of replicates samples belonged to several functional feeding Surber sampler was positioned, 2) each rock and sites might lead to more statistically groups including collector-gatherers, collector- and piece of cobble in the square plot was significant results, it is still possible to achieve filterers, shredders, scrapers, herbivorous picked up and vigorously scrubbed by hand statistically significant results with a relatively piercers, and predators (Figure 5). In meadows

Journal of Undergraduate Research – Volume X 24 Natural Sciences of both activity levels (active and abandoned) almost exclusively at abandoned meadows. the abandoned meadows. Another scraper and at both locations (inflow and outflow) the The caddisfly Hydroptilidae was the only caddisfly family, Uenoidae, was only found most abundant feeding group was collector- piercer family present in this study. This three times during this study, twice at the gatherers, which accounted for more than half family was found to be significantly more inflow of an active meadow, Mill Creek, and of the total insects collected during this study. abundant at abandoned meadows than active once at the outflow of an abandoned meadow, The feeding habits of individual families can meadows (p-value = 0.0539). Hidden Valley. be found in Table 3, as well as the ANOVA Predators Shredders results regarding each family. While the predator feeding group overall The only shredder feeder that produced Collector-Filterers did not produce any significant results, significant results was the stonefly Nemouridae. One noteworthy feeding group was individual families within the predator group Nemouridae was significantly more abundant the collector-filterers. For both active and displayed some significant results. One such overall in active meadows than in abandoned abandoned meadows, the average number of predator was the stonefly Chloroperlidae, meadows (p-value = 0.0569). While not collector-filterers was greater at the meadow’s which was more abundant in the active statistically significant, Nemouridae also outflow than the inflow (p-value = 0.0731). meadows than the abandoned meadows, behaves as though it may have an interaction Families of collector-filterers were Simuliidae, regardless of inflow or outflow locations between inflow/outflow and activity level Hydropsychidae, and Brachycentridae. (p-value = 0.0477). Another predacious (p-value= 0.1243). Nemouridae was the The dipteran family Simuliidae, which stonefly, Perlidae, displayed an interaction most abundant shredder family from this accounted for the majority of the collector- effect between activity level and location study and influenced the overall patterns filterers, displayed the same pattern as the in which their abundance was significantly seen in the distribution of shredder feeders. overall collector-filterer group between the higher at the active inflow than any other site Large amounts of variation between replicates inflows and outflows (p-value = 0.0447). The (p-value = 0.0423). A predacious dipteran, caused the interaction for Nemouridae to abundance of Simuliidae likely influenced the Dolichopodidae, displayed they same not be statistically significant, even though in overall pattern for its entire feeding group. interaction behavior as Perlidae (p-value = figure 5 this interaction appears quite drastic The other two families of collector- 0.0126). Additionally, Dolichopodidae was for shredders. The collector-gatherer Elmidae filterers, Brachycentridae and Hydropsychidae, significantly more abundant at inflows than also showed the same insignificant pattern as are both caddisflies and were less abundant outflows, regardless of the meadow’s activity Nemouridae, in which abundance appears to than Simuliidae. Neither Brachycentridae nor level (p-value = 0.0725). Although these results increase more between the inflow and outflow Hydropsychidae were found to have significant are statistically significant, it’s important to of the active meadows than the abandoned differences in inflow and outflow abundance. consider that only six total Dolichopodidae meadows. Although not always significant, However, Brachycentridae was significantly specimens were found during this study, and the presence of this same pattern across several more abundant overall in active meadows all six were found at the inflow to Mill Creek, taxa should be noted due to the possibility of than in abandoned meadows, when inflow an active beaver meadow. it not being due to random chance. and outflow abundances are averaged for each Scrapers meadow. (p-value = 0.000436). The opposite The scraper feeding group also displayed Discussion was true of the family Hydropsychidae, several interesting differences in distribution The results of this study can be which was significantly more abundant in across the meadows. For both active and grouped into three categories regarding the abandoned meadows than in active meadows, abandoned meadows, the average number of macroinvertebrate community composition: regardless of the location on the meadow scrapers was greater at the meadow inflow than differences across inflows and outflows, (p-value = 0.0863). the meadow outflow (p-value = 0.0008). The differences across active and abandoned Collector-gatherers families of scrapers included Heptageniidae, meadows, and an interaction effect of The collector-gatherer feeding group Ameletidae, Uenoidae, and Glossosomatidae. these two factors. First, differences in the contained the majority of aquatic insects in The scraper mayfly Heptageniidae was found abundances of several taxa across inflows and this study. While the collector-gatherer group to be significantly more abundant at the outflows, regardless of meadow type, suggest overall did not have any differences between inflows than the outflows for meadows of that processes occurring within floodplain inflows and outflows or between activity levels, both activity levels (p-value = 1.29E-05). meadows are altering the downstream aquatic individual families within the group displayed Because Heptageniidae was a very abundant insect communities. Second, some taxa are some significant results. A collector-gatherer scraper family, Heptageniidae influenced the more abundant in active meadows overall, mayfly, Leptophlebiidae, had a significant overall patterns seen in the distribution of regardless of inflow or outflow location, interaction between location and activity level scraper feeders. suggesting that some characteristic of study (p-value = 0.0680), in which the abundance In addition to Heptageniidae, there were areas are affecting the streams upstream of was found to increase between inflow and several less abundant scraper families. Another the meadows as well as downstream of the outflow in the active meadows, and decrease scraper mayfly family, Ameletidae, was meadows. Finally, for some taxa an interaction between inflow and outflow in the abandoned significantly more abundant in active meadows occurs in which active meadows have different meadows. Leptophlebiidae was also more than abandoned meadows (p-value = 0.0301). changes between the inflow and outflow abundant at the inflows than the outflows It is worth noting that Ameletidae was very communities than abandoned meadows. of meadows of all activity levels (p-value uncommon in this study and was only present This interaction suggests that some aquatic = 0.0774). Two other collector-gatherer at one active meadow, Hidden Valley, and one insect taxa are more sensitive to differences families were significantly more abundant in abandoned meadow, Cow Creek. The family between active and abandoned meadows active meadows than abandoned meadows, Glossosomatidae is a scraper caddisfly which and the processes occurring within them that regardless of inflow or outflow location; these had a significant interaction between location impact outflow habitat. The mechanisms families were Baetidae (p-value = 0.00757), and activity level (p-value = 0.0691), in which causing these three different categories of and Elmidae (p-value = 0.0034). the abundance was found to increase between results are not directly examined in this Piercers inflow and outflow in the active meadows, study. Information from past publications The feeding group piercers were found and decrease between inflow and outflow in on the feeding habits and life history traits

25 Journal of Undergraduate Research – Volume X Natural Sciences of different aquatic insects can help predict gatherers were more abundant at meadow Active meadow outflows may be a highly possible mechanisms driving these differences outflows, the scraper mayfly familyproductive habitat due to the downstream in aquatic insect communities.8,9 Heptageniidae, was found in greater numbers flux of nutrients from processes such as the Differences between inflows and outflows at meadow inflows. Since scrapers feed by breakdown of woody debris and frequent For some families, their average grazing on periphyton attached to substrate, flood events occurring within active beaver abundance was significantly differenta difference in the amount of periphyton meadows.1,2 between inflows and outflows. The families between inflows and outflows could be A second possibility regards the idea that in Figures 6 and 7 demonstrate examples affecting the abundance of scrapers.8 Nutrients the presence or absence of beavers in these of this type of relationship. Due to their stored near the sediment water interface meadows is due in part to the meadow’s land location, outflow habitats are subject to the promote patches of periphyton, which are use history. Past land use could be influencing ecological impacts of processes occurring in also influenced by stream geomorphology other overall characteristics of the streams and the meadows upstream, while inflow habitats and oxygen availability.11 Scrapers are also their riparian areas in addition to influencing are not. Meadow processes include storage specialist feeders, which makes them more whether the meadows are active or abandoned. and gradual breakdown of woody debris, sensitive to disturbances or pollutants that An area’s history could also be impacting capture of nutrients such as organic carbon in impact a specific food source, unlike collector- the availability of food sources necessary for sediments during flood events, and a slowed filterers, which are more generalist feeders.9 the presence of dietary specialists including movement of water through unconfined valley Without further study, it is difficult to say scrapers such as Ameletidae, and shredders segments.1 While abandoned meadows lack which of many possible factors could be such as Nemouridae.9 some of the complexity and characteristics leading to lower Heptageniidae abundances at While many families and orders of active meadows, similar process may still the meadow outflows. were more abundant in active meadows, occur in meadows of both activity levels. This Although technically statistically only two families were more abundant in is because historic beaver activity leaves an significant, results regarding differences abandoned meadows, Hydroptilidae and impact on a meadow that gradually degrades between the inflow versus the outflow Hydropsychidae. Hydroptilidae are piercers over time.10 For example, Moraine Park, one abundance of Dolichopodidae might not that extract the contents of algae cells with of the abandoned meadows in this study, indicate anything about the impacts of land specialized mouthparts.8 Algae may be more was noted in a 2012 study to be a site where use and beavers. This family was only present abundant in abandoned meadows than active beaver activity had greatly influenced post- in one location on one meadow, Mill Creek’s meadows. When visiting these sites, it was glacial floodplain aggradation, despite having inflow. It is possible that unique characteristics observed that abandoned meadows sometimes no beaver activity at the time of that study.10 of Mill Creek’s inflow are creating a favorable had less riparian vegetation than active The increased outflow abundance of the habitat for this family; these characteristics meadows. Less vegetation at abandoned collector-filterer family Simuliidae and the may or may not be related to the past land meadows may be allowing more sunlight to collector-gatherer family Leptophlebiidae use and beaver activity in the downstream penetrate the water and promote the growth could suggest differences in availability meadow. of algae in abandoned meadows. Returning of FPOM between meadow inflows and Differences between active and abandoned to sites and simultaneously sampling for algae outflows. Simuliidae and other collector- meadows and macroinvertebrates could help test this filterers feed by capturing decomposing Many aquatic insect taxa, including seven hypothesis. Meanwhile, Hydropsychidae are FPOM that is suspended in the water column families and three entire orders, had higher collector-filterers that construct a silk capture as it travels downstream. Collector-gatherers abundance in active meadows compared net which they use to strain out particulate such as Leptophlebiidae also feed on FPOM to abandoned meadows, regardless of the matter. They are limited to particulate matter that has settled on the stream bottom.8 One location on the meadow. The families in in a specific size range such that it won’t possible mechanism for patterns of increased Figures 8 and 9 demonstrate examples of pass through or break their capture net. It’s collector-filterers and collector-gatherers at this type of relationship. Since inflows are possible that the streams with active meadows the outflows is that river-floodplain meadows assumed to be unaffected by the downstream do not produce the correct size of particles for add FPOM to the water as it travels through meadow processes, one would expect to find Hydropsychidae. meadows. This would lead to increased differences between activity levels only when Interactions between meadow activity level and levels of FPOM at outflows, creating a more considering the outflows as they compare to location favorable habitat for the Simuliidae and inflows. However, since this is not the case, In this study, inflows of meadows of Leptophlebiidae. Floodplain meadows are it appears that there are differences between both activity levels were assumed to be known to trap particulate organic matter active and abandoned meadows that are equally unaffected by the processes occurring during flood events when the stream is forced impacting stream communities at both inflow downstream in the meadow. When processes out of the channel and into unconfined and outflow locations. There are several such as storage of woody debris and cycling meadow segments.1 However, the sampling possible explanations for the overall increased of nutrients are unequal between active for this study was performed in August, after abundances of certain taxa in active meadows. and abandoned meadows, there may be an all sites had passed their peak flows and flood For most of the aquatic insect taxa in interaction between meadow activity level and events. Another possible mechanism for this study, the adult forms are capable of meadow location such that the relationship increasing FPOM at outflows is the gradual flight. Adult aquatic insects are known to fly between inflow and outflow communities breakdown of woody debris stored within upstream from their larval habitat to lay eggs, differs between active and abandoned floodplain meadows, continuously creating resulting in upstream larval populations being meadows. The families in Figures 10 and particulate organic matter.1 It is possible that supplemented by downstream populations.12 11 demonstrate examples of this type of the slow breakdown of woody debris in these If active meadow processes are creating relationship. meadows could be providing an abundant particularly productive habitats at outflows, it One such interaction was observed in the food source for collector-gatherers and is possible that some of the adults emerging scraper family Glossosomatidae, which was collector-filterers at the meadow outflows. from outflow habitats are traveling upstream more abundant at outflows than inflows in While collector-filterers and collector- to the inflow locations to lay their eggs. active meadows, but not in abandoned

Journal of Undergraduate Research – Volume X 26 Natural Sciences

meadows. This suggests that processes Dolichopodidae, Uenoidae, and Perlidae are effective biological indicators, processes occurring in active meadows are leading all displayed interactions as well. The impacting them could be causing much to more favorable outflow habitats for interactions displayed by these three families greater impacts on the stream ecosystem and Glossosomatidae or for their food source, involved a decrease in abundance between downstream water quality. periphyton. One possibility is that increased the inflow and outflow of the active meadow, periphyton thrive downstream of active and no change between inflow and outflow Acknowledgements meadows due to increased nutrients stored in of the abandoned meadow. However, for Thank you to Professor Tim Covino and the sediments of active meadows.11 Nutrient Dolichopodidae, all six specimens found Professor William Clements at Colorado State rich sediments stored both in and just during this study were found at the inflow of University, both whose advice and guidance downstream of active meadows could be due Mill Creek, an active meadow. It is possible were invaluable throughout this project. I to higher carbon accumulation and retention that characteristics unique to Mill Creek’s thank Tristan Weiss for advice on project design in beaver meadows through processes such as inflow are creating a favorable habitat for and sampling in beaver meadows. Thank you flooding.1 It is also possible that competition this family; these characteristics may or may to Tyler Lampard for assistance with fieldwork for periphyton with other scraper taxa such not be related to the past land use and beaver during benthic macroinvertebrate sampling. as Heptageniidae affects the distribution and activity in the downstream meadow. Similarly, abundance of Glossosomatidae. only three Uenoidae were found in this study References The collector-gatherer familyand only in two places: the inflow of Mill 1Wohl, E., Dwire, K., Sutfin, N., Polvi, L. and Bazan, R. (2012) “Mechanisms of carbon storage in Leptophlebiidae displayed the same Creek and the outflow of Hidden Valley. mountainous headwater rivers.” Nature Communications interaction behavior as seen in the family Again, since this family was only found in 3.1. Pg 1-8. Glossosomatidae. Collector-gatherers are these two locations, it becomes increasingly 2Wegener, P., Covino, T. and Wohl, E. (2017) one of the more generalist feeding groups questionable whether or not these patterns are “Beaver-mediated lateral hydrologic connectivity, of macroinvetebrates.9 They eat decaying related to river-floodplain meadow processes. fluvial carbon and nutrient flux, and aquatic ecosystem 8 metabolism.” Water Resources Research 53. Pg 4606- particulate matter trapped in the sediments. Creating a statistical model that accounts for 4623. Since active meadows are effective at trapping site-specific characteristics of the sampling 3Cairns, J. and Pratt, J. (1993) “A history of biological nutrients and particulate organic carbons in locations could help determine if patterns in monitoring using benthic macroinvertebrates.” Freshwater Biomonitoring and Benthic Macroinvertebrates 10.27. sediments during flood events, they may be these rarely found families are significant to Pg 10-27. contributing to downstream habitats with the processes of river-floodplain meadows. 4Poff, N., Olden, J., Vieira, N., Finn, D., Simmons, more nutrient-rich sediments, which would Perlidae, a predacious stonefly, displayed M. and Kondratieff, B. (2006) “Functional trait niches be a possible mechanism for the interaction the same interaction as Dolichopodidae and of North American lotic insects: traits-based ecological 1 applications in light of phylogenetic relationships.” behavior seen for Leptophlebiidae abundance. Uenoidae, but was not as uncommon and was Journal of the North American Benthological Society Although not statistically significant, found repeatedly and at multiple locations. 25.4. Pg 730-755. it is important to note that other taxa This predator may rely on some prey source 5Wallace, J. and Webster, J. (1996) “The role of displayed a similar interaction behavior that is more abundant at active inflows. macroinvertebrates in stream ecosystem function.” Annual Review of Entomology 41.1. Pg 115-139. to Glossosomatidae and Leptophlebiidae. Conclusions and future actions 6Merritt, R. and Cummins, K. (Eds.). (1996) An Two examples are the shredder family The use of aquatic macroinvertebrates as introduction to the aquatic insects of North America. Nemouridae and the collector-gatherer indicators of how anthropogenic disturbance Kendall Hunt. family Elmidae. Similar to Glossosomatide affects stream quality has been repeatedly 7Downing, J. (1979) “Aggregation, transformation, 3 and the design of benthos sampling programs.” Journal and Leptophlebiidae, both Nemouridae and demonstrated by past studies. While of the Fisheries Board of Canada 36.12. Pg 1454-1463. Elmidae increased in abundance between the specific mechanisms impacting the 8Merritt, R., Cummins, K. and Berg, M. (2017) inflow and outflow of active but not abundances of different taxa in these meadows Methods in Stream Ecology, Volume 1 (3rd ed.). abandoned meadows. Shredders, such as is uncertain, it is clear that these meadows do Academic Press. Pg 413-433. 9Cummins, K. and Klug, M. (1979) “Feeding Nemouridae, consume decomposing plant affect the aquatic insect communities. The ecology of stream invertebrates.” Annual review of matter and wood, also called coarse particulate results of this study suggest that both active ecology and systematics 10.1. Pg 147-172. organic matter (CPOM).8 The gradual and abandoned meadows are affecting the 10Polvi, L. and Wohl, E. (2012) “The beaver breakdown of stored woody debris in active outflow communities, and that in some cases meadow complex revisited–the role of beavers in post- glacial floodplain development.” Earth Surface Processes beaver meadows could result in more CPOM the processes in active meadows benefit certain and Landforms 37.3. Pg 332-346. at outflows. Also, shredders, like scrapers, are outflow taxa more strongly. Also it appears 11Coleman, R. and Dahm, C. (1990) “Stream a feeding group of dietary specialists, which that some characteristic of the active meadows geomorphology: effects on periphyton standing crop and makes them more sensitive to disturbances or their surroundings is resulting in increased primary production.” Journal of the North American Benthological Society 9.4. Pg 293-302. and pollutants that could impact their food abundance of several taxa both upstream and 12 9 Müller, K. (1982) “The colonization cycle of source than other feeding groups. Collector- downstream of the active meadows. The use freshwater insects.” Oecologia 52.2. Pg 202-207. gatherers like Elmidae are generalists that of aquatic insects as a biological indicator eat decomposing particulate organic matter in this study supports the findings of past trapped in substrates, which could be effected studies, which have shown that important by meadow processes such as the trapping of ecological processes happen in both active nutrients. These insignificant interactions and abandoned beaver meadows.2,10 Both in Nemouridae and Elmidae could be due active and abandoned beaver meadows are to a variety of differences between active ecologically significant areas and merit further and abandoned meadow processes or due study due to their importance to water quality to chance. Completing a similar study with and carbon cycling. Future studies could more meadows and more replicates could be help link the macroinvertebrate community one way to investigate if there are interactions composition to the specific physiochemical between meadow activity level and location in and habitat characteristics of active and groups other than Glossosomatidae. abandoned meadows. Since aquatic insects

27 Journal of Undergraduate Research – Volume X Natural Sciences

Figure 1: Study sites located in RMNP (left). Shows the 12 sampling locations at the inflows and outflows of the six river- floodplain meadows sampled for this study. All meadows are within the boundaries of Rocky Mountain National Park.

Figure 2: Meadow layout. A satellite view of Moraine Park, a river-floodplain meadow abandoned by River&floodplain. beavers. The inflow and Meadow. outflow sites are just above and below the section of stream that becomes braided as it travels across the meadow.

Journal of Undergraduate Research – Volume X 28 Natural Sciences

Average'Number'of'Aqua/c'Insects'

per'Surber'Sample'Avg. # aquatic insects per Surber Sample

300300 '

250250 '

200200 '

150150 ' Surber'Sample' Avg. # aquatic insects per Surber Sample Avg.

100100 '

50'50 Avg.'Number'of'Aqua/c'Insects'per' 0 0' Inflow Outflow Inflow Outflow

Inflow'ActiveOu9low' InflowAbandoned' Ou9low' Ac*ve( Abandoned(

Figure 3: Average number of aquatic insects per Surber sample. This Figure 4: Average number of families per Surber sample. This graph graph shows the average number of aquatic insects per Surber sample for shows the average number of different aquatic insect families per Surber each of the four treatment types: active inflow, active outflow, abandoned sample found at each of the four treatment types. inflow, and abandoned outflow.

Figure 5: Functional feeding groups at inflows and outflows. Pie chart shows the relative abundances of the six functional feeding groups at the four different treatment types.

29 Journal of Undergraduate Research – Volume X Natural Sciences

Figures 6 and 7: Examples of families that are significantly different between inflow and outflow locations. Figure 6 shows the average number of Simuliidae, a collector-filterer dipteran, which are more abundant at outflows than inflows. Figure 7 shows the average number of Heptageniidae, a scraper mayfly, which are more abundant at inflows than outflows. Significance codes for p-values: NS > 0.1; 0.1 > * > 0.05; 0.05 > ** > 0.01; *** <0.01

Figures 10 and 11: Examples of families that demonstrate an interaction effect between activity level and location. Figure 10 shows the average number of Leptophlebiidae, a collector-gatherer mayfly, at the four treatment types. Figure 11 shows the average number of Glossosomatidae, a scraper caddisfly, at the four treatment types. Both Leptophlebiidae and Glossosomatidae demonstrate an intraction effect, with their greatest abundance occuring at active meadow outflows. Journal of Undergraduate Research – Volume X 30 Natural Sciences

Research Process Project design Sample collection Taxonomic Statistical analysis Table 1: Conceptual diagram and field site during field work sorting of and data → → → of the research process. This selection samples interpretation diagram outlines the steps taken in completing this study.

Meadow Name Sampling Locations: Active or Abandoned?

Cow Creek Inflow Abandoned Outflow Hidden Valley Inflow Abandoned Outflow Upper Beaver Meadows Inflow Abandoned Outflow Moraine Park Inflow Abandoned

Outflow Table 2: Site Classification. There Mill Creek Inflow Active were twelve total sampling locations on six meadows. Each meadow Outflow was sampled twice, once at the inflow and once at the outflow. Glacier Creek Inflow Active All meadows are classified as Outflow either Active beaver meadows or Abandoned beaver meadows.

Significantly differed in abundance across: Order Family Feeding Habit Activity Levels Locations Interaction: Activity x Location Ephemeroptera Table 3: Results by family. The table shows the functional feeding Ameletidae Scraper Active** groups of aquatic insect families from Baetidae Collector-gatherer Active** this study. The last three columns Heptageniidae Scraper Inflow*** indicate if the family was found Leptophlebiidae Collector-gatherer Outflow * Active outflow * to be significantly more abundant in active or abandoned meadows, Plecoptera inflows or outflows, and if there was Chloroperlidae Predator Active** any interaction effect between the two Nemouridae Shredder Active * factors. Perlidae Predator Active inflow** 1. Significance codes for p-values: NS > 0.1; 0.1 > * > 0.05; 0.05 > ** > Trichoptera 0.01; *** <0.01 Brachycentridae Collector-filterer Active*** 2. Families with only one total Glossosomatidae Scraper Active outflow* specimen found across all sites during Hydropsychidae Collector-filterer Abandoned * this study were omitted from this list Hydroptilidae Piercer Abandoned * (Siphlonuridae, Dytiscidae, Dixidae, Ptychopteridae). Uenoidae Scraper Active inflow** 3. Families without significant Coleoptera ANOVA results were omitted from Elmidae Collector-gatherer Active*** this list (Ephemerellidae, Perlodidae, Diptera Lepidostomatidae, Limnephlidae, Dolichopodidae Predator Active** Inflow* Active inflow ** Rhyacophilidae, Athericidae, Ceratopogonidae, Chironomidae, Simuliidae Collector-filterer Outflow** Emphidadae, and Tipulidae).

31 Journal of Undergraduate Research – Volume X Natural Sciences

Abandoned Meadows Active Meadows Order Family Cow Creek U.B. Meadows Hidden Valley Moraine Park Mill Creek Glacier Creek Inflow Outflow Inflow Outflow Inflow Outflow Inflow Outflow Inflow Outflow Inflow Outflow Ephemeroptera 16 14.5 18.25 40 63.75 22.75 39.25 25.75 47 67.75 31.75 31 Ameletidae 0.75 - - - 3 9.25 ------Baetidae 5 7.75 3.25 36.5 35 5.25 6.25 12.75 11.5 45.75 22.5 23.5 Ephemerellidae 6.5 6 5.5 2.75 4.25 7.75 4.5 6.25 11 17.25 0.75 2.75 Heptageniidae 3.5 0.75 9.5 0.25 21.5 0.5 28.5 6.75 24.5 3 8.5 4.5 Leptophlebiidae 0.25 - - 0.5 - - - - - 1.75 - - Siphlonuridae ------0.25 Plecoptera 3.25 12 2.75 19.75 49.75 9.5 2.5 0.5 11.5 104.25 4.5 4.25 Chloroperlidae 1.75 6 1.75 0.75 1.25 0.75 1 0.25 1.25 3 4.25 3.25 Nemouridae 1.25 2.5 0.5 0.25 46 8.5 0.75 0.25 7.5 99.25 - 0.75 Perlidae - 2.25 ------1.5 - 0.25 0.25 Perlodidae 0.25 1.25 0.5 18.75 2.5 0.25 0.75 - 1.25 2 - - Trichoptera 8.5 35 1 3.25 13.5 1.75 2 1.75 5.75 32.25 1.25 3.25 Brachycentridae 1 2.25 - - - - 0.5 1 3.5 31.25 1 0.25 Glossosomatidae 0.25 0.25 - - - - 1 - - - 0.25 2.5 Hydropsychidae 3.5 2.5 ------0.25 Hydroptilidae 3 29.5 - 0.25 - - - 0.25 - - - 0.25 Lepidostomatidae - 0.25 0.5 1.75 ------Limnephilidae - - - 0.75 0.5 0.75 ------Rhyacophilidae 0.75 0.25 0.5 0.5 13 0.75 0.5 0.5 1.75 1 - - Uenoidae - - - - - 0.25 - - 0.5 - - - Coleoptera 6 6 9.5 1 1.25 2 4.5 10 18.5 57.75 4.25 5 Elmidae 6 6 9.5 0.75 1.25 2 4.5 10 18.5 57.75 4.25 5 Dytiscidae - - - 0.25 ------Diptera 76.75 138.5 1.25 13.25 81 60.75 32.5 16 44.75 79.75 16.75 6.25 Athericidae 0.25 - - - - 1.25 - - - 0.5 - - Ceratopogonidae - - - 0.25 - 0.5 - - 0.25 - - - Chironomidae 75.25 131.5 0.5 5 57 53.75 32.25 14 41 66.5 16.25 5.5 Empididae - - - - 6.75 ------Dixidae - - - - 0.25 ------Dolichopodidae ------1.5 - - - Ptychopteridae ------0.25 - - Simuliidae 1.25 6.5 0.75 7.75 17 5.25 0.25 2 2 12.5 0.5 0.75 Tipulidae - 0.5 - 0.25 ------Table 4: Averaged raw data. The table shows the raw averaged data, sorted by family. The abundance of each family is reported for each of the 12 sampling locations. Abundances reported here are the averages of 4 Surber samples taken per location. There were a total of 48 Surber samples taken during this study.

Journal of Undergraduate Research – Volume X 32 Canon and Blues: Diverse Influences on Philip Larkin’s “Aubade” By Brandon Pahl University of Iowa

When considering writers who represent or not Larkin himself completely avoided Eliot’s the opposite sex (iv) at dawn…”6 By this diversity, in terms of work as well as their influence in particular shall be examined later). definition, Larkin’s “Aubade” seems to be a life, one rarely encounters Philip Larkin. Larkin seemed to embody the Movement’s traditional aubade only in the sense that it takes Especially after the publication of his collected aesthetic of simplicity not only in his poetry but place at dawn.7 While it is not necessary to correspondence, Larkin’s reputation seems in his humble working life as a librarian in the know the definition, etymology, and history of to have been cemented as that of a crotchety northern coastal town of Hull. He never had its title to enjoy or even understand “Aubade,” conservative, an upholder of traditional verse as pretensions about being upper-class, and in fact possessing this information opens the poem well as traditional values. Such a way of viewing seems to have been quite opposed to the stuffy, up to further interpretation. The word “love” Larkin the man, it should be stated, is not snobbish attitude that upper-class Englishmen is used only twice in “Aubade,” first in relation necessarily incorrect (his letters abound, after (and especially Englishmen of letters) embody. to remorse (“the love not given” (12)), second all, in expressions of admiration for Margaret His working-class sensibilities entailed a in explicit relation to death (“Nothing to love Thatcher, subtle jabs at modernist literature, “lifelong enthusiasm for jazz,” as well as an or link with” (29)), making Larkin’s poem an and even some casual racism). When applied to “irreverent rejection of the pieties associated ironic subversion of the traditional form.8 In his poetry, however, this way of viewing him is with ‘highbrow’ arts.”3 His personal artistic Larkin’s world, love is not only powerless in not only reductive and simplistic but downright ethos was one of understandability: he wanted the face of death, but subordinate to it. Love incorrect. Much in Larkin’s poetry suggests that to write poetry that even England’s uneducated is not even considered as a means of escaping he was not a complete literary conservative, but laity could relate to and comprehend. or conquering death, whereas other means are that, in crafting his unique and nuanced work, The very first line of “Aubade” is one that considered and duly met by Larkin with acerbic he drew on varied elements from canonical any working-class man, from any country for skepticism. literature, modernism, and even the popular that matter, could perhaps relate to: “I work Critical attention seems to be most often blues music of his time. all day, and get half-drunk at night” (1).4 directed at “Aubade’s” atheistic view of religion, Although Larkin wrote four distinct The rhythms and diction of the beginning of a “vast, moth-eaten musical brocade,” (23) volumes of poetry, and many uncollected “Aubade” in particular are stark and simplistic, but Larkin also examines and dismisses classic poems, this analysis shall focus on one following strict iambic pentameter and philosophical methods of confronting death, poem, “Aubade,” which is arguably the most consisting largely of monosyllabic words, thus albeit in terms that the layman may easily representative of his entire work. It came to maximizing its accessibility even to those who digest.9 In addition to religion, “Aubade” also fruition in 1977, near the end of Larkin’s life, a have no idea what the words “iambic” and takes aim at two major Greek philosophical period of nearly total creative stagnation. Thus, “monosyllabic” mean. However, one should systems, Epicureanism and Stoicism, though “Aubade” is perhaps his dreariest and most not be tricked by the gambit of simplicity at the neither is mentioned by name in the poem. pensive poem, a bleak and candid reflection poem’s beginning, and thereby underestimate Only the most basic ideas of these two on the inescapability of death. As with many the ways in which “Aubade” is more than it philosophies are suggested and criticized, with of his poems, it is at first glance a simple work seems. For, despite Larkin’s publicly expressed the Epicurean viewpoint on death being the with a simple theme; however, it reveals upon wish that his poetry be simple and pure, almost first to visit the examination table. “Aubade” closer examination that he was not the typical, as if it originated in a vacuum, much in this last finds “an aporia in the proposition that ‘No homogeneous English poet he is sometimes great poem of his suggests the contrary. rational being / Can fear a thing it will not made out to be. feel’…,” a way of looking at death that is central Tradition and the Western Canon to Epicurean philosophy.10 Larkin turns this The Movement The very title of “Aubade” goes against the sentiment on its head by arguing that “losing Some (though not all) of the context philosophy that Larkin, and by extension the the means to feel is precisely ‘what we fear.’”11 needed to understand the origins of “Aubade” Movement, supposedly upheld. Rowe is quick Speaking of death in these distanced terms is can be derived by understanding the literary to point out the French origin of the title, tantamount to an attempt to escape or deny movement Larkin belonged to, at least during something that is rare for Larkin as he usually it, making it little better than religion’s explicit his early career: “the Movement.” “The “took the official Movement line on foreign denial of death in favor of an afterlife. For Movement” is characterized as embodying “a cultures;”5 namely, that to reference or use any Larkin, the sheer emotional horror of death general post-war period of reconstruction” in language other than English was something should not be overlooked but faced—although its approach to literature.1 Movement poets of a faux pas. Sometimes the mot juste simply we also cannot face it with a so-called “stoical” sought a “return to traditional forms and does not exist in English, which is ostensibly attitude. regular structures of rhyme and rhythm,” just the case for “Aubade,” a word that no one who With regards to Stoicism, “Aubade” is at as the English were seeking a restructuring of has not studied literature extensively (whether odds with this philosophy in both its ancient their society after the devastating events of the they be upper, middle, or lower class) will fully and modern conceptions. Original Stoicism second World War.2 This, supposedly, meant a comprehend. could indeed have passed as a religion or cult, turning away from the modernist aesthetics of Osborne defines an aubade in these terms: and one of the main Stoic beliefs was “that death pre-war American poets like T.S. Eliot and Ezra “a type of lyric in which (i) a narrator of one is not the losing of life but the returning of it to Pound in favor of newer, simpler verse (whether sex (ii) sings a love song (iii) to a member of its Creator.”12 It may not fall into the category

33 Journal of Undergraduate Research – Volume X Literature of “moth-eaten musical brocade” (an epithet Modernism…? the rough age of the speaker in “Aubade” is not obviously aimed, most of all, at Christianity), Though Larkin’s own personal way of so easily estimated, it seems hard to imagine but it still seems to be an idea that the speaker of incorporating and subverting tradition in his death is as remote for him, especially in the “Aubade” would find suspect. Equally suspect poetry is unique, the very act of incorporation lines “Not to be here, / Not to be anywhere, is modern Stoicism, which is defined as an and subversion is not. To assert the contrary / And soon…” (18-20).20 It bears repeating attitude of “courage or fortitude, indifference would be to ignore one of the most fruitful that Larkin wrote these lines when (though to pain or fear,” an attitude that hardly fits this literary movements in history, modernism, he did not know it at the time) he had less poem’s speaker.13 The poem contradicts these which, in poetry, has arguably its greatest than a decade to live, whereas Eliot composed sentiments with lines that are brimming with representative in T.S. Eliot. Larkin’s attitude “Prufrock” when he was still young, with The an almost sing-song mockery: “Being brave / towards Eliot seems to have been somewhat Waste Land still ahead of him—a work that Lets no one off the grave” (38-39).14 Courage ambivalent, judging at least by his letters and would appear to bear even less of an influence in the face of death is something to be treated critical writings, although he has had much on Larkin. sneeringly. Any expressed lack of fear in the to say about other notable representatives of Nevertheless, it is difficult to imagine face of death is most likely a pretense; everyone modernism, one of whom is almost incessantly a Larkin without Eliot, or for that matter, possesses at least a modicum of said fear, and named alongside Eliot. He expresses a Larkin without modernism in general. That denying it is pointless. So much for philosophy. bald “dislike of Pound and Picasso,” in the which he viewed negatively still had an effect With “Aubade,” Larkin firmly maintains that introduction to All What Jazz, his collection of on him, and in some ways his entire oeuvre the philosophies of antiquity, as revered and music reviews, and further inveighs against the including “Aubade” can be viewed as an answer influential as they are, and with their notions of entire modernist movement, as represented not to modernism (whether or not it is a refutation rationality and indifference, offer no true respite only by Pound in poetry and Picasso in visual of modernism is contentious). One would against the overwhelming terror of death. art but by Charlie Parker in music, by saying be remiss however to focus mainly on things As if incorporating and then subverting that “it helps us neither to enjoy nor endure.”18 that Larkin himself viewed either negatively or classical Greek philosophy in his poetry were (One wonders if the same argument could not ambivalently (some of which may have landed not enough, Larkin does the same for the most also be made against “Aubade” itself.) In any in his poetry only subconsciously), because, revered English writer of all time: William case, Larkin’s expressed disdain for modernism contrary to appearances, there were some things Shakespeare. It needs hardly to be said that, at would appear to preclude the influence of Eliot. that he enjoyed and which influenced him. least when one writes in English, one cannot Yet dislike for a literary movement or artist Larkin, like any adequate poet before him, did avoid Shakespeare’s influence—nor, for that is not enough to escape their impact, especially not find inspiration solely in the antiquated or matter, avoid comparison to him, especially when they have been as impactful as Eliot has. even in the recent past, but also in the present, when one’s verse becomes as well-known and The Movement may have designated Eliot the in the form of the popular jazz and blues music potentially canonical as Larkin’s is. Larkin, official status ofbête noire, but unofficially his of his time. naturally, was aware of all this. Many of his influence still seems to sift its way into the work earlier poems use phrases and expressions culled of Larkin, supposedly the most representative Jazz and Blues directly from Shakespeare, though the material poet of the Movement. Russell finds the most An appreciation for jazz had possessed is often treated with a “schoolboy irreverence” prevalent convergence of Eliot with Larkin Larkin from a young age, although his love as in the poem “Toads,” where “the desire to in “Aubade,” arguing that the line “‘[t]he for it is sometimes seen as peculiar. In his shout ‘Stuff your pension!’ to one’s employer is anaesthetic from which none come round’… biography of Larkin, Booth writes that “[for] ‘the stuff / That dreams are made on.’”15 Larkin’s has clearly borrowed from Eliot’s vision of the Larkin jazz was a private passion, shared with a attitude towards Shakespeare could perhaps be evening ‘Like a patient etherized upon a table’ small number of male friends. He never tired, seen as that of a sort of working-class jokester in ‘Prufrock.’”19 One wonders, however, if this in particular, of the ‘inexhaustible vitality of the who, while acknowledging Shakespeare’s image was so “clearly borrowed.” Has Larkin blues’…”21 One would hardly expect Larkin, indispensability, is still not afraid to poke fun. intentionally lifted this image from Eliot’s whose poetry in addition to his personal Parallels may also be drawn between second most well-known poem, or has he simply demeanor seems so saturnine, to be associated Larkin and the most famous of Shakespeare’s come up with a similar (not the same) image with something that possesses an “inexhaustible characters, Hamlet. These two are similar in unconsciously? Furthermore, if the former vitality.” And yet this phrase belongs to Larkin that they can both be equally “melancholy and is the case, might this also be categorized as a himself; it is culled from All What Jazz. Larkin’s sardonic” and both have an obsession with death “subversion,” in the vein of the more obvious, admiration for jazz and blues was deep and that can best be observed in Larkin’s “Aubade” aforementioned subversions of canonical work? sincere, and the influence of this music upon and Hamlet’s “To be or not to be” soliloquy.16 In any case, an Eliot influence on Larkin, him may be observed not only in All What Jazz However, Larkin still finds ways to differ from and especially on “Aubade,” cannot now be but in his poetic work. the greatest creation of the greatest English dismissed too easily. Their poetry shares not The simplicity of certain types of jazz and writer. “For Hamlet, Epicurus works; the only extremely broad themes of death but blues songs especially affected Larkin’s poetry: thought of absolute annihilation cures his fear narrower themes of the dehumanizing effects of “The twelve-bar blues formula, that modern of death,” whereas for Larkin no such remedy modernity and city life—although the degree version of the ancient aubade…gave him the exists, least of all in ancient Greek philosophy.17 of subtlety with which Larkin and Eliot each example of a strict but infinitely variable artistic In Larkin’s case, death is also explored with an approach these themes varies. Both “Aubade” discipline: ‘for all its formal simplicity it is rarely intense, autobiographical candor (“Aubade”, and “The Love Song of J. Alfred Prufrock” monotonous’”22 “Formal simplicity” would whose first word is “I,” testifies to this), whereas concern themselves with these themes, but appear to be the key phrase here, another Shakespeare creates a character who may or (and here Larkin’s distance from Eliot may be quotation from All What Jazz, the introduction may not be autobiographical to think about observed) they do so from opposite viewpoints. to which has already been acknowledged above death for him. Larkin’s poetic approach to death A younger man is clearly the speaker of Eliot’s as a key text for Larkin’s aesthetic philosophy, is unique; it is distinct, though perhaps not “Prufrock,” a man who recognizes death but in poetry as well as jazz. His stance against jazz fundamentally different, from Shakespeare’s. only as a remote certainty, embodied for him with modernistic tendencies, as exemplified by chiefly in the thinning of one’s hair. Although Parker, Davis and Coltrane, was firm. Jazz

Journal of Undergraduate Research – Volume X 34 Literature

after Coltrane “started to be ugly on without saying, is a wholly unoriginal theme close examination, are, in the end product of purpose”; it was characterized by “chaos, hatred in the grander context of world literature. the poem, kneaded together so seamlessly that and absurdity,”23 and while one could make the Innumerable libraries could be stuffed with the eye of the layman (as well, sometimes, as case that “hatred” can sometimes be found in books of mediocre death-poems. “What is the professional) fails to notice them. Aubade, Larkin’s poetry, “chaos” and “absurdity” seem untraditional in [‘Aubade’],” what differentiates philosophy, modernism, blues: it is possible to mostly to be absent. Chaos and absurdity this poem from reams of dross “is its method of see “Aubade” as both the synthesis of all of these preclude accessibility for Larkin, which is dealing with an anxiety that is both unacceptable things and the antithesis of them. All of these arguably his central aesthetic tenet. The jazz and inescapable.”28 This “method” involves elements come together, under Larkin’s hand, and blues influences in Larkin’s poetry, rather complete sincerity, something which is to form something new: his “Aubade.” than muddling the message of the poem, serve undeniably derived from the blues, a form of to make the message even clearer and more music that is built around plain-spokenness. References/Footnotes digestible for the average reader. The lexicon of “Aubade” is largely simple, and 1Swarbrick, A. (2008) Out of Reach: The Poetry of Philip Larkin. Macmillan Pres. Pg 70. Leggett provides a detailed analysis of the when metaphors appear (which is rare), they 2Ibid. Pg. 71. blues influences in Larkin’s last great poem, are characterized by a distinct lack of whimsy. 3Ibid. Pg. 70. arguing that “‘Aubade’ is not a blues, but…we One might even criticize these few metaphors 4Larkin, P. (2012) The Complete Poems of Philip can trace its strength to the blues.”24 “Aubade” for being unimaginative: “The sky is white Larkin, edited by Archie Burnett. Farrar-Straus-Giroux. 29 Pg. 115. would, in other words, be a radically different as clay” (48) by no means scintillates with 5Rowe, M.W. (2011) “‘Aubade’: Death and the (and probably less interesting) poem without originality, nor is it intended to do so. This and Thought of Death.” Philip Larkin: Art and Self: Five the influence of blues music flowing through other analogies in “Aubade” serve as crushing Studies. Palgrave Macmillan. Pg. 167. it. Leggett pays special attention to the first line reminders of the grounded nature of death: it is 6Osborne, J. (2014) “Radical Citation: ‘Aubade’.” Radical Larkin: Seven Types of Technical Mastery. Palgrave of “Aubade,” with its drab iambic pentameter a certainty of life that is as plain as “clay,” a word Macmillan. Pg. 207. and its references to “[w]orking and drinking,” that could fit perfectly in the earthy vernacular 7Even this could, however, be complicated by the both of which “are…common properties of of the average blues singer. poem’s first line, which implies repetition. “Aubade” may the blues.”25 These coarse, simplistic terms If such an analogy is not brimming with not describe one particular dawn but a great many which have come to morph together in the narrator’s mind. are blues terms. A more traditional poem (a uniqueness, it is, however, easily comprehended. 8Larkin, P. (2012) The Complete Poems of Philip more poetic poem, one might even say) would In no way does it betray Larkin’s professed Larkin, edited by Archie Burnett. Farrar-Straus-Giroux. certainly have found more eloquent ways of desire to be genuine and understandable, to Pp. 115-116. phrasing these subjects, if it decided to portray craft his poetry so that it is accessible even to the 9Ibid. 10Osborne, J. Pg. 231. them at all. Larkin, however, is not concerned simplest layman—in short, to tell the truth. In 11Ibid. with being flowery, or with veiling the essential this he has more in common with the blues than 12Ibid. Pg. 233. meaning of his lines. He, like many blues with most English-language poets that came 13Ibid. musicians, wishes to state the situation as before him, and this desire for truthfulness is 14Larkin, P. (2012) The Complete Poems. Pg. 116. 15Kerrigan, W. (1998) “Larkin and the Difficult matter-of-factly as possible. It is here that his found even in his earliest work. Who else, after Subject.” Essays in Criticism: A Quarterly Journal of poetry differs drastically not only from his all, would write a poetry collection entitled Literary Criticism. 48.4. Pg. 294. modernist predecessors but from even earlier The Less Deceived, other than someone who 16Ibid. relatives like Hardy or Yeats, who most of the wanted people to be “less deceived” by poetry, 17Ibid. Pg. 298. 18Larkin, P. (1985) All What Jazz: A Record Diary time refrained from such blunt expression. to find in poetry not inaccessible fluff but ideas 1961-1971. Farrar-Straus-Giroux. Pg. 27. Though the blues undeniably flows and language that were close to their everyday 19Russell, R.R. (2007) “Echoes of Eliot’s ‘The Love through “Aubade,” it is important to recognize experience? “Aubade,” as a later Larkin poem, is Song of J. Alfred Prufrock’ in Larkin’s ‘Aubade.’” Heldref that a white Englishman’s poem can only come exceptionally in-tune with everyday experience, Publications. Pg. 235. 20Larkin, P. (2012) The Complete Poems. Pg. 115. so close to the true form. For as much as Larkin with its talk of postmen, wardrobes, curtains, 21Booth, J. (2014) Philip Larkin: Life, Art and Love. is concerned with being genuine, “Aubade,” et cetera. It possesses as well a subject that Bloomsbury. Pg. 317. if it can be considered blues, would be an everyone can understand, as everyone must 22Ibid. 23Larkin, P. (1985) All What Jazz. Pg. 21. inauthentic example of the genre, not only one day face death. “Aubade” “is as much about 24 due to Larkin’s background, but also because it being undeceived as it is about death.”30 The Leggett, B. (1999) Larkin’s Blues: Jazz, Popular 26 Music, and Poetry. Louisiana State University Press. Pg. 95. uses “an oral tradition within a written form.” idea of being undeceived is one that Larkin did 25Ibid. Pg. 97. (Thus, even the Beatles’ attempts at blues are not derive from the English canon. Rather, he 26Ibid. Pg. 99. more authentic than Larkin’s.) The blues are found it in the blues. 27Ibid. Pg. 102. 28Ibid. meant to be sung aloud with plaintive, furious Conclusion 29Larkin, P. (2012) The Complete Poems. Pg. 116. cries, not imparted to a sterile page. That the It is something of a commonplace that 30Leggett, B. Pg. 108. genre is a product of the long and painful works of fiction and poetry that serve a blatant struggle of black Americans for freedom and political or moral message tend not to last. creative expression means that it can never be Less of a commonplace (perhaps because it faithfully copied by someone such as Larkin. seems even more obvious) is the idea that work Nevertheless, Leggett makes the bold claim which either bears its influence obviously or, “that ‘Aubade’ is much closer to a blues tradition conversely, bears only one obvious influence, than to the long English tradition that preceded also tends not to last. The poetry of Philip it.”27 Larkin does not copy the blues, but, as Larkin generally, and “Aubade” as the possible with the works of English tradition, seeks to crown jewel of his entire oeuvre, do not fall reinterpret them not just in terms of form but into any of these amateurish traps. Unless one also of content. looks at “Aubade” through a quite myopic lens, Analyzing the content of “Aubade,” one one inevitably finds not one, overwhelming returns to a consideration of its main and influence but multiple diverse ones, which, arguably only subject, death, which, it goes although they make themselves apparent under

35 Journal of Undergraduate Research – Volume X J.R.R. Tolkien and Environmental Concerns in Mid-20th Century England By Drew Heiderscheidt University of Northern Colorado

On December 5, 1952, a haze descended throughout his entire life. He went as far as trees in The Lord of the Rings as individuals upon London. On average, visibility dropped to call The Lord of the Rings “my internal was indicative of their importance to to below 500m, but in the center of the city tree.”4 Tolkien’s adoration of trees also led him. Tolkien’s primary response to the it was less than 50m. The streets were dark, to an abiding fear of their mistreatment. “I obliteration of trees in the real world was empty, and enveloped in silence. People am (obviously) much in love with plants the Old Forest. In it, Old Man Willow was stayed in their homes, avoiding going out and above all trees, and always have been; the primary danger to Frodo—the story’s as much as they could. Five days later, the and I find human maltreatment of them as Hobbit protagonist—and his companions. smog lifted, and 4,000 were dead, according hard to bear as some find ill-treatment of The first time Willow appeared was on the to one British official at the time. The Great animals,” he wrote to the Houghton Mifflin first leg of Frodo’s journey to Mordor, the Smog of London, as it later became known, Company in 1955.5,6 It was the neglect of dark region ruled by the story’s antagonist, was the worst incident of air pollution in trees that led Tolkien to consider himself a Sauron, when they traveled through the British history, and was caused by a variety guardian of forests. In a letter to the Editor Old Forest. When the Hobbits (Frodo, of different factors, including air inversion of the Daily Telegraph, Tolkien wrote that he Sam, Merry, and Pippin) took a stop to rest, and low-quality fuel, which was overall would defend all trees against their enemies.7 Old Man Willow attacked them and nearly largely a result of a growing trend toward Tolkien’s fondness for trees is prevalent suffocated Merry and Pippin.9 However, industrialization. Despite the scale of this in his works, especially in the symbolic the Old Forest and Old Man Willow were disaster, air pollution and other forms of importance they take on. For example, the not inherently malevolent, as they appeared environmental degradation were nothing White Tree of Gondor in The Lord of the on the surface; rather, the “Old Forest was new to England, which alarmed many.1 The Rings is emblematic of the health of Gondor hostile to two legged creatures because of alarm of those in England manifested itself in as a civilization. So, when the White Tree of the memory of many injuries.”7 Thus, by the artistic media of the time, notably in the Gondor is sick, Gondor as a whole is also in virtue of trying to protect themselves from works of J.R.R. Tolkien. decline, and vice versa. Matthew Dickerson bipeds, the Old Forest and Old Man Willow With the swift development of industry and Jonathan Evans observed Tolkien’s were manifestations of the destruction of in 20th century England came a myriad of apparent fear of neglecting trees when they forests in the real world. Because in real life, environmental problems such as deforestation noted how Treebeard, a wizened animated “If someone starts hacking at a tree with an and air pollution. As a result of the quick tree in The Lord of the Rings, posited that axe the rooted tree has to stand and take expansion of commerce at this time, people cutting down trees for necessities is distressing the blows,” this was Tolkien’s way of giving became more conscious of environmental enough, but unnecessarily tearing down trees forests a defense mechanism in the face of degradation, something illustrated through is unacceptable.6 It is apparent that Tolkien environmental degradation.10 the lens of literature and governmental considered the felling of trees immoral— In addition to deforestation, air pollution regulation, such as The Clean Air Act of so much so that the character of Treebeard was also a substantial problem in England 1956. People generally considered the shift acted as a mouthpiece for him to convey his during the 20th century. Factories in England to mechanization in England detrimental, thoughts on the subject. When Pippin, a released immense amounts of smoke into the and many romanticized the times before any Hobbit, asked Treebeard whose side he was air— something Tolkien observed in a letter type of mechanization as a sort of “organic on (i.e., good or evil), Treebeard replied he to Rayner Unwin on October 24, 1952, when wholeness.”2 Environmental concerns such as was on nobody’s side because “nobody cares he wrote “This charming house has become. . these are present in the works of the British for the woods as I care for them, not even the . drenched with fumes,” and “I regret to note philologist J.R.R. Tolkien, most famously Elves nowadays.”8 that the billowing cloud recently pictured the author of The Hobbit and The Lord of Tolkien’s concern for trees in England did not mark the fall of Barad-dur [Sauron’s The Rings. In Tolkien’s works, there are a was justified. The amount of forest felled tower], but was produced by its allies.”11 multitude of references to his environmental from 1918 to 1945 totals up to 1,024,000 According to the environmental historian views, including the character of Saruman, acres—over 3 percent of the total land area I.G. Simmons, air pollution in England at a dark wizard who “sacrifices the value of in England.2 Tolkien mourned the loss of so this time came in the form of “smoke from permanence of sustainability for his grand many different trees in part two of The Lord the quality of bituminous coal used, which scheme of domination and ownership.”3 of the Rings, The Two Towers. In response was still about 40 million tonnes/yr.”2 The Tolkien’s works were a representation of to the destruction of a large swath of forest, sheer amount of smoke released into the air environmental worldviews in England Tolkien wrote—through Treebeard—“Many was recognized by James Law, a combustion during the 20th century, in which people of these trees were my friends, creatures I engineer, when he said that in thirty years he were concerned with environmental had known from nut and acorn; many had had “never seen conditions worse than those degradation—particularly deforestation, voices of their own that are lost for ever now. in industrial cities and towns of the north air pollution, and industrialization. Not And there are wastes of stump and bramble during the past two years.”12 There were only this, but his characters reflected both where once there was singing groves.”8 The major health concerns associated with the industrialist and environmentalist mindsets. agony Tolkien felt when trees were destroyed high quantity of coal being used in England Tolkien was fascinated by trees was apparent, and his personification of at this time. In 1952, the English government

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stopped rationing small-type coal, called use was immense. By 1954, 173,000 acres industrialization. “I looked on [the valley “nutty slack”, and as a result, “Sulphur worth of land in England and Wales had Isengard is located in] and saw that, whereas dioxide [reached] the highest concentration become unusable due to the iron and steel it had once been green and fair, it was now recorded since detailed monitoring of this industries.2 Indeed, in “The Scouring of the filled with pits and forges,” Gandalf said. compound had begun in 1932.” In the end, Shire,” Tolkien illustrated the problems of He then added that around all of Saruman’s the Great Smog of London made possible by mills and industry. “[The mills are] always projects “a dark smoke hung and wrapped ubiquitous “nutty slack” led to the deaths of a-hammering and a-letting out a smoke itself about the sides of Orthanc [Saruman’s 4,000 people in England.13 In the aftermath, and a stench,” Farmer Cotton (another tower].”9 It is obvious that Isengard was the British Parliament passed the Clean Air Hobbit) complained, and added that they in the midst of a similar development to Act of 1956, which regulated the amount had polluted the nearby river.16 Likely, these that of Britain in the 19th century. This of pollution that could be put into the air.14 mills were inspired by the ones Tolkien industrialization is noted by Dickerson and Tolkien himself felt the effect of air pollution witnessed during his childhood.17 The extent Evans in Ents, Elves and Eriador—a book on his own health, when he wrote in a letter of industrial development in England during about Tolkien’s environmental worldviews— to his son Christopher, “I have been afflicted the twentieth century was enormous, with when they wrote that Isengard “is shown with what may be. . . a ‘virus’. . . of which sand and gravel production increasing from in the image of industrial smokestacks: the risk is steadily mounting in this polluted 127 million tons in 1950 to 192 million vents and shafts spouting and belching fire country.”15 To Tolkien, air pollution was tons in 1960.2 Tolkien bemoaned this very and foul fumes.”6 Tolkien noted the harm ever-present, and impossible to ignore. industry in “The Scouring of The Shire,” of industrialization when he described the In one of the final chapters of The Lord when he wrote “Great wagons were standing land around Isengard: “No trees grew there, of the Rings, Tolkien described air pollution in disorder in a field of beaten bare grass. but among the rank grasses could still be in the native land of the Hobbits, the Shire: Bagshot Row was a yawning sand and gravel seen the burned and axe-hewn stumps of There was a whole line of the ugly quarry.”16 Simply put, the Shire was almost ancient groves.”8 From Tolkien’s description, new houses all along Pool Side, where the entirely industrialized by Saruman. Even in the reader visualizes the stumps of trees, the Hobbiton Road ran close to the bank. An Tolkien’s descriptions of Saruman, there was putrid smells, and other traces of a place in avenue of trees had stood there. They were an inherent opposition to industry. Saruman the midst of industrialization. Treebeard all gone. And looking with dismay up to “has a mind of metal and wheels; and he described the situation, when he said, “Orcs the road towards Bag End they saw a small does not care for growing things, except came with axes and cut down my trees. chimney of brick in the distance. It was as far as they serve him for the moment,” I came and called [the trees] by their long pouring out black smoke into the evening Treebeard complained in The Two Towers.8 names, but they did not quiver, they did air.16 For Tolkien, the threat of industrialization not hear or answer: they lay dead.”8 This It is not by mere coincidence that was forever looming on the horizon. description of the pain caused by cutting Tolkien described the scene at Bag End in An interesting comparison may be down trees showed Tolkien’s anxieties of a way that highlights clouds of black smoke made between the Shire at the beginning industrialism. Saruman personified an billowing through the air— it reflected of Lord of the Rings to the one at the anthropocentric worldview—he used nature his perspective that air pollution hindered end. At the beginning, Tolkien described to increase his own power, at the expense of England through its exacerbation of negative Hobbits as loving “peace and quiet and all living things.6 Tolkien juxtaposed the still- health impacts and interruption of the once good tilled Earth: a well-ordered and well- industrializing land of Isengard with that of bucolic aesthetic that the country held. farmed countryside was their favorite haunt. the already-industrialized Mordor, Sauron’s Industrialization, and Tolkien’s views on [Hobbits] do not and did not understand abode. it, existed throughout his works. His views or like machines more complicated than a Mordor, the home and fortress of the of industrialization’s effects are especially forge-bellows, a water-mill, or a hand-loom.9 primary antagonist Sauron, is the most prevalent in the chapter “The Scouring of This was evocative of English sentiment debased region in Tolkien’s legendarium, The Shire,” in The Return of the King, where before industrialization, when the most with the word “shadow” being regularly used Saruman forced industrialization upon The impressive technology was no more advanced as a descriptor. When Frodo and Sam arrived Shire. In a description of the Shire as it was than a hand-loom. By the end, the Shire at the outskirts of Mordor, it was described forcibly industrialized, Tolkien wrote: was transformed at the hands of Saruman as truly terrible. “[Frodo and Sam] had come The great chimney rose up before [Frodo, into an industrializing wasteland, blanketed to the desolation that lay before Mordor. . . Sam, Pippin, and Merry]; and as they drew by smoke and pockmarked with mills and A land defiled, diseased beyond all healing,” near the old village across the Water, through quarries. However, the Shire was not defined Tolkien wrote of the Dead Marshes.8 The rows and rows of new mean houses along by mills that pour out black smoke, but by fact that Tolkien used “desolate,” “defiled,” each side of the road, they saw the new mill vineyards, corn fields, woods, by vegetables and “diseased” to highlight the status of the in all its frowning and dirty ugliness: a great like turnips and carrots, fruits like apples land that Frodo and Sam entered shows how brick building straddling the stream, which it and plums, and flowers like snapdragons and badly damaged it was. Dickerson and Evans fouled with a steaming and stinking outflow. daffodils.18 echoed this when they wrote, “The ground All along the Bywater Road every tree had in Mordor is not only ‘fire-blasted,’ as with been felled.16 In The Two Towers, Tolkien painted a picture bombs, but also ‘poison-stained,’ as when Tolkien’s description of the houses of the spread of industrialization through factories’ toxic refuse contaminates the earth, as “mean” and his characterization of the the use of the fortress of Isengard, home water, and the air.”6 Tolkien’s description mill as “frowning” and “ugly” spoke to his to the dark wizard (and one of the primary of the Dead Marshes (on the outskirts of opposition to industry and urbanization. antagonists of Lord of the Rings), Saruman. Mordor) is telling: It is unsurprising that Tolkien felt this way In his speech about Sauron, Saruman, and [In the Dead Marshes] nothing lived, towards large industrial processes like iron Isengard at the Council of Elrond in The not even the leperous growths that feed on or coal extraction, as the amount of land Fellowship of the Ring, the great wizard rottenness. The gasping pools were choked that was made unsuitable for any further Gandalf evoked imagery reminiscent of with ash and crawling muds, sickly white and

37 Journal of Undergraduate Research – Volume X Literature grey, as if the mountains had vomited the the mantle of environmentalism, Tolkien of the King, Sam believes Frodo is dead filth of their entrails upon the lands about. imbued his best known creation—Hobbits— because he was stung by a giant poisonous High mounds of crushed and powdered rock, with strong environmentalist views. In the spider, Shelob (although he was actually great cones of earth fire-blasted and poison- view of this author, environmentalism falls paralyzed). As a result, Sam took the One stained, stood like an obscene graveyard in on a spectrum, ranging from passive to Ring. And, whereas Sauron or Saruman saw endless rows, slowly revealed in the reluctant active. Those on the passive side support ultimate power when they had the ring, Sam light.8 actions to protect the environment without saw only one thing: a garden so large that This portrayal has a counterpart in taking action themselves, whereas those it could be its own country.16 In Tolkien’s Charles Dickens’s descriptions of the who are active take initiative to protect the universe, this makes Sam the true hero of the industrialization of England during the 19th environment. Ultimately, Hobbits fall on the story, and he wrote that it was “absolutely century, especially in his novel Hard Times. extreme action side of that spectrum. essential to the study of his (the chief hero’s) However, the word choice used by Tolkien In a letter to Milton Waldman some character, and to the theme of the relation here warrants further analysis. The fact that time in 1950, Tolkien explained Hobbits of ordinary life (breathing, eating, working, nothing lived in the area is reminiscent of collective environmentalism, when he wrote begetting) and quests, sacrifice, causes, and the derelict land in Dickens’s descriptions that Hobbits were “represented as being more the ‘longing for Elves,’ and sheer beauty.”25 of industrializing England. And the land in touch with ‘nature’ (the soil and other Indeed, Sam was representative of people’s in the Dead Marshes (on the outskirts of living things, plants and animals).”25 The views in post-industrialized England: they Mordor) could easily be used to describe that fact that Hobbits love the earth puts them missed the beauty and connection with same dilapidated land across vast swathes of in a similar category to environmentalists, nature of England’s past. English land. As a way to describe Mordor, who try to protect the earth. Both Dickerson When J.R.R. Tolkien began work on Tolkien used imagery he had gained from and Evans took note of this when they wrote The Lord of the Rings in the 1937, after the “war, industrialization, and urbanism,” to that “Hobbits are close to the earth, and publication of The Hobbit, environmental demonstrate how Sauron had destroyed the they are closely associated with the material degradation was on his mind. Almost fifteen land.6 Tolkien expanded upon the desolation substance of the soil. They wear no shoes, years later, upon publication, The Lord of the in Mordor when he illustrated the land and their walking around barefoot keeps Rings represented environmental concerns in surrounding Frodo and Sam in Mordor as them in direct physical contact with the mid-twentieth century England. People were “ruinous and dead.”16 earth,” essentially meaning that Hobbits concerned about deforestation, particularly Part of the inspiration for Mordor was were closer to the earth than other creatures after two World Wars, which decimated the First World War. Tolkien was a veteran in Tolkien’s legendarium because they were England’s forests; about air pollution, of the First World War, specifically the constantly in physical contact with it.6 From especially after the Great Smog of London Battle of the Somme, which was one of their introduction, it was clear that Hobbits in 1952; and industrialization, which many the largest battles of the war. By the end of were connected with nature and realized felt irrevocably changed the environment the battle, both sides lost 1.2 million men that they did not have dominion over the in England. Tolkien represented this in his combined, and by the end of the war as a environment.26 descriptions of Middle-earth, filled with whole over 10 million people died.16,19 “The Tolkien was an avid gardener, and this pristine environments, like the Shire, as well Dead Marshes and the approaches to the was a trait that he projected onto Hobbits, as degraded environments such as Mordor. Morannon,” Tolkien wrote to L.W. Forster, particularly Bilbo Baggins (the protagonist Not only this, but Tolkien’s characters often “owe something to Northern France after of his earlier work, The Hobbit), Frodo, and reflected both environmentalists (think: the Battle of the Somme.”20 The Battle of Sam. In a letter to his son Christopher, he Hobbits, Treebeard, and others), and the Somme, and other battles, considerably described his love for the garden. “When a industrialists like Sauron and Saruman. In destroyed the forests of Europe. In the novel gleam of sun (about 11) got through [the doing so, Tolkien created a microcosm that The Somme, A.D. Gristwood noted that garden, it] was breathtakingly beautiful. . . was reflective of environmental worldviews “not a green thing survived the harrowing I stood in the garden hatless and uncloaked in 20th century England. of the [artillery] shells. Constant barrages without a shiver, though there must have had churned the land into a vast desert of been many degrees of frost,” Tolkien wrote, Acknowledgements shell-craters, one intersecting another like in awe.27 This close relationship with the I would like to thank Dr. T.J. Tomlin the foul-pock markings of disease.”21 Indeed, environment was seen in environmentalists for instilling in me the idea to combine the First World War decimated the forests of the time, especially those who believed that Tolkien and Environmental History, and of France almost entirely, surely witnessed rural England was one of “enduring values.”2 assisting me in the early stages of writing; Dr. during his tour there. The landscape went Throughout The Lord of the Rings, Hobbits Kristin Boivard-Abbo for her suggestions on from huge swathes of European beech trees, have an inherent love for anything that different directions and sources, as well as for to almost total devastation.22,23 In the Revue grows. Bilbo and Frodo Baggins, both well- letting me borrow her extensive knowledge des Eaux et Forets during the First World to-do Hobbits, never hired a housekeeper, a of J.R.R. Tolkien; and, Dr. Karen Barton War, one contributor remarked how not maid, or even a cook—and yet, they hired for her unending support, editing, and only the artillery was destroying the forests of gardeners. And, if that were not enough, numerous suggestions for this article over the France, but also the militaries there: “Vicious Tolkien named many Hobbits after flowers: past few years. [military forest] exploitations’ left stumps think of the Hobbit women who appear cut too low and felled plantations before sporadically throughout the series, all of References they reached maturity.”24 Because of the war, them bearing names like Rose, Daisy, or even 1Brimblecombe, P. (2017) “London (1952): 6 An Enduring Legacy.” In Air Pollution Episodes. the ecosystem of France (and other parts Marigold. Rather, Hobbits lived in harmony Brimblecombe, P. ed. UK Limited. Pg 57-72. of Europe) changed entirely, with a diverse with their natural surroundings. 2Simmons, I.G. (2001) An Environmental History polyculture being turned into a monoculture Of all the Hobbits, Sam Gamgee is of Great Britain: From 10,000 years ago to Present. 22 Edinburgh University Press. dominated by Conifers. the most prominent environmentalist—his 3 Despite having never explicitly taken profession is even gardening. In The Return Elder, John. (2006) “Foreword.” In Ents, Elves

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and Eriador: The Environmental Vision of J.R.R. Tolkien. Dickerson, M. and Evans, J. The University of Kentucky Press. Pg ix-xxi. 4Tolkien, J.R.R.(1962) Letter to Jane Neave, September 8-9, 1962. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 319-322. 5Tolkien, J.R.R. (1955) Letter to the Houghton Mifflin Company, June 5, 1955. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 217-223 6Dickerson, M. and Evans, J. (2006) Ents, Elves and Eriador: The Environmental Vision of J.R.R. Tolkien. The University of Kentucky Press. 7Tolkien, J.R.R. (1972) Letter to the Editor of the Daily Telegraph, June, 1972. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 419-420. 8Tolkien, J.R.R. (1954; repr. 1993) The Two Towers. Houghton Mifflin. 9Tolkien, J.R.R. (1954; repr. 1993) The Fellowship of the Ring. Houghton Mifflin. 10Flieger, V. (2000) “Taking the Part of Trees: Eco- Conflict in Middle-earth.” In J.R.R. Tolkien and His Literary Resonances” Views of Middle Earth. Clark, G. and Timmons, D. eds. Greenwood Press. Pg 147-158. 11Tolkien, J.R.R. (1952) Letter to Rayner Unwin, October 24, 1952. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 161-163. 12National Smoke Abatement Society. (1940) Smoke Abatement in Wartime. Copy Located at National Society for Clean Air and Environmental Protection, Brighton, UK. 13Thorsheim, P. (2006) Inventing Pollution: Coal, Smoke, and Culture in Britain since 1800. Ohio University Press. 14Clean Air Act, 1956, 4 & 5, chapter 52 (United Kingdom). 15Tolkien, J.R.R. (1971) Letter to Christopher Tolkien, June 2, 1971. In The Letters of J.R.R. Tolkien. Carter H. ed. Houghton Mifflin Harcourt. Pg 408-409. 16Tolkien, J.R.R. (1955; rept. 1993) The Return of the King. Houghton Mifflin. 17Carpenter, H. (1977; repr. 2000) J.R.R. Tolkien: A Biography. Houghton Mifflin. 18Sarjeant, W.A.S. (2001) “The Shire: Its Bounds, Food and Farming.” Mallorn 39. Pg 33-37. 19Keegan, J. (1998; repr. 2000) The First World War. Vintage Books. 20Tolkien, J.R.R. (1960) Letter to Professor L.W. Forster, December 31, 1960. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 303. 21Gristwood, A.D. (2002) “The Wasteland.” In The Vintage Book of War Fiction. Faulks, S. and Hensgen, J. eds. Vintage Books. Pg 38-48. 22Hupy, J.P. (2008) “The long-term effects of explosive munitions on the WWI battlefield surface of Verdun, France.” Scottish Geographical Journal 122. Pg. 167-184. 23Hupy, J.P. (2008) “The Environmental Footprint of War.” Environment and History 14. Pg 405-421. 24Pearson, C. (2012) Mobilizing Nature: The Environmental History of War and Militarization in Modern France. Manchester University Press. 25Tolkien, J.R.R. (Undated) Letter to Milton Waldman. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 143-160. 26Elgin, D. (1985) The Comedy of The Fantastic: Ecological Perspectives on the Fantasy Novel. Greenwood Press. 27Tolkien, J.R.R. (1944) Letter to Christopher Tolkien, December, 1944. In The Letters of J.R.R. Tolkien. Carter, H. ed. Houghton Mifflin Harcourt. Pg 106-107.

39 Journal of Undergraduate Research – Volume X “In the Public Interest”: The Historiography of Crusade Finance By Lee Morrison Florida State University

I. Introduction the other hand, it enabled the laity who secular taxes” for the duration of this section. Logistically, a medieval crusade were not fit for combat to participate in These secular taxes proved to be models for presented many difficulties, particularly in the crusade in a tangible way, contributing later papal programs, most notably in their regards to its financing. The act of raising toward it on an individual level without methods of collection and assessment. The an army, transporting it to the Holy Land, actually traveling with the army. This was levies set a precedent for the cooperation sustaining it upon arrival, and providing meant to ensure that those funds would go between ecclesiastic and secular authorities further support in the event that it succeeded toward combatants only, eliminating the in crusade taxation, and its history is one in acquiring territory, was an enormous large portion of noncombatants who tended of adaptation and flexibility. Innocent III’s challenge that demanded considerable to follow the armies toward the Holy Land, decision to adapt similar measures in 1200 economic contribution. Crusading was as seen in the First Crusade. was not borne out of a desire to squeeze cash incredibly expensive. Pope Innocent III Crusade taxation underwent from his clergy but was instead a product of and his successors were aware of this and considerable development in the thirteenth practicality. He saw a longstanding problem realized that in order for any crusade to and fourteenth centuries, and though these (inconsistent and decentralized financing of succeed, it had to be well funded. In 1208, taxes were often contentiously received, crusades), and he saw a framework in place Innocent declared a regional income tax on they did raise valuable funding. Though that already had mixed elements of lay and a tenth of the revenues of the clergy and intended for crusade, privileges and taxes ecclesiastical participation and which had laity in France to support the crusade against were eventually granted to secular rulers, already produced successful collections, Cathar heretics in the south of the country. who enthusiastically collected them but albeit at a local level in England. The Innocent based this tax on the notion that often without using the money which was decision to apply this framework to the Latin “those acting in the public interest should raised for that express purpose. As secular clergy and base it upon papal authority was be sustained by public taxes”.1 Since 1199, rulers claimed the right of clerical taxation in a natural one. Innocent had sought to find a solution to the their domains against similar assertations by The opening of the Vatican archives inherent difficulties of organizing a successful the ecclesiastical government of the Church, in 1881 made materials that would prove crusade, especially by his push to introduce the papacy in this period increased both the invaluable to the study of the medieval widespread clerical taxation as a source of frequency of its taxation and the sources papacy available to students and scholars funding. Scholars of crusade finance have of its revenues. These abuses soured the for the first time. Prior to their opening, traced the history of taxation and established popular attitude toward crusade taxation, no comprehensive treatment of the papacy’s a connection between the early tax initiatives not because of a loss of belief in the cause of finances during this period existed. In of Henry II and the later adoption of the crusading, but due to the constant levying of 1934, William Lunt published what would income tax as papal policy by Innocent III. taxes, ostensibly for that purpose, which were become the first synthesis of medieval papal However, papal taxation was seen then not actually carried out once the money finance in which he examined the various through a lens of cynicism by mid-twentieth was raised. The financial abuses which sources of revenue available to the medieval century historians who considered the abuses contributed to the Protestant Reformation, papacy, though he made no mention of of fiscal policy observed during the late notably the sale of indulgences by the expenditures or repercussions of papal thirteenth to sixteenth centuries as a natural papacy, should be understood as having finance.2 Expenditure would be treated in development stemming from the programs developed not out of the crusading policy of depth by a myriad of later historians. Lunt of crusade finance established by Innocent the thirteenth century papacy, but through noted that papal taxation was influenced by III and his successors. Recent scholarship later abuses by secular rulers and the Avignon twelfth century secular taxes and adopted has suggested otherwise. While the popes.A their framework while simultaneously relationship between secular and ecclesiastic basing justifying extraction as an extension taxation has proven consistent throughout II. Secular Precedents to Ecclesiastical of the papal right of plenitude potestatis, by the historiography, the nature of the papacy’s Taxation which the papacy could “assert its power crusade policy can be understood as being Papal taxation of the clergy was not over the Patrimony of the Church for whom based in spirituality and practicality, as an idea without precedent. Instead, it was the crusades were fought.”3 As papal taxes opposed to materialism. A central element inspired by secular initiatives of the twelfth developed, so too, he argued, did the Curia, of crusade policy was the establishment of century. Although Innocent III is credited as and the “mere organ of the [papal] household taxation as a source of funding. Crusade the first Pope to impose direct taxation upon had become a great department of state.”4 taxation served a dual purpose. On one the clergy in 1200, he was preceded by almost Fred Cazel and James Brundage hand, it sought to provide a solution forty years of secular taxation which would furthered the notion that the twelfth century to the economic challenges created by continue to influence papal taxation after secular taxes inspired crusade taxation during crusading armies as a means of funding their his pontificate. The levies of 1166, 1183, the pontificate of Innocent III, who wanted transportation, supply, and manpower by 1185, and most famously 1187 formed the to expand and regularize them to apply to providing financial support to the magnates basis of clerical taxation. This group of taxes the papal patrimony at large.5 The twelfth who led their local forces on campaign. On will be referred to as the “twelfth century century levies were the result of an agreement

Journal of Undergraduate Research – Volume X 40 History between Henry II of England and the kings also saw the first attempt at ecclesiastic further delayed its completion.23 The of France to tax the general populations of participation when Clement III requested three Archbishops assigned with carry out their realms to support the crusade.6 The use that bishops contribute to the collections in collections each held their own provincial of Templars and Hospitallers, first appointed addition to the laity.16 Cazel concluded that councils to decide on how to execute the in 1185 to collect these taxes, lent them the Saladin Tithe offered the most promising collection within their jurisdiction, and they an element of ecclesiastic representation.7 basis for crusade taxation, but its successors disagreed on the allowance of exceptions.24 Innocent wished to expand this ecclesiastic were instead appropriated by secular princes They convened in order to decide on the role while still cooperating with the kings and popes for purposes other than aiding the issue but deliberations were delayed by a to ensure that taxation went smoothly and Crusader States.17 jurisdictional dispute between Archbishop of without opposition. Cazel pointed out that Though Clement III required that Bourges and the Benedictine abbot of Deols, the 1185 tax, which Lunt had previously bishops should participate in the 1187 tax, whom the Archbishop excommunicated considered to be nonexistent and based on Innocent III’s declaration of a fortieth in according to his role as papal legate. The a forged ordinance, was not only carried out 1200 represented the first general tax on Archbishops proved overzealous in their but was instrumental in the development of clergy. In addition to the fortieth on clerical execution of the collection, excommunicating the “Saladin Tithe” of 1188. Cazel argued incomes, Innocent stipulated that he and so many clergymen for fraud that Honorius that the 1185 tax was an example of the the cardinals would pay a tenth of their own had to also grant them temporary power of blending of secular and ecclesiastic authority revenues.18 Clerical opposition to taxation absolution, as it was deemed excessive for the present in the twelfth century levies. The was immediate and largely unceasing sheer number of excommunicates to journey tax was declared by Henry II and Philip thereafter. This created collection problems. to Rome for appeal.25C Honorius turned Augustus with the consent of their bishops Whereas the English crown enjoyed a back to using curial collectors not because he and counts, consisted of a three year tax centralized authority within its territory desired it, but because it was the only feasible of a hundredth on income and moveables and some prior history of implementing method of collection, despite the clerical (personal possessions which are not attached broad crusade taxation, the papacy possessed complaints.D to the land), was backed by an indulgence neither. France, Collins, Bird, and Asbridge granted by the bishops of Normandy, Innocent III attempted to use papal furthered the work of Cazel and Kay. and was collected by members of military collectors in 1200, but clerical uproar France, writing in 2005, found a precedent orders.8 Furthermore, the exemptions of made it clear that such a measure would be for both secular and ecclesiastic taxation in necessities of profession from assessment deeply unpopular. Cazel and Kay showed the intellectual and social advances of the and the terminology of the 1185 ordinance that Innocent and his successors were aware twelfth century. He argued that the increase bore striking similarity to the ordinance of of this and did not initially favor outright in wealth at this time caused society to turn the Saladin Tithe.9 Brundage remarked that centralization. Kay examined Innocent’s to two institutions of authority, the papacy this sort of adaptation of previous taxes was attempts to balance local and centralized and the monarchies, to provide frameworks characteristic of the financial system of the authority in 1200 and 1215, using local for law and stability.25 After 1188, both crusades.10 clergy to collect taxes under the supervision institutions began developing greater Ecclesiastical sanctions were used to of Roman officials.19 He also adopted Henry administrative capabilities, leading to joint enforce the twelfth century collections, II’s use of parish chests in 1213 as a means of increases in the regularity of church and further blending secular and church authority collecting alms for the Holy Land.20 Powell royal government, growth in education, and into the process of financing endeavors in also argued that Innocent was cautious about a general rise in intellectual development. the Holy Land. Henry II’s 1166 tax, which outright centralization, and attempted to Collins also pointed out an increasing called for two pennies per man for the first learn and adapt from the organizational and focus on financial bureaucracy among the year and one thereafter, was to be collected in operational failures of the Fourth Crusade. papacy and a trend of financially oriented chests placed in each parish church, overseen During that venture, the crusade army found popes. Cencio Savelli, before becoming by priests and enforced by sanctions.11 This itself impoverished and in considerable Honorius III, compiled the first version of was developed further with Baldwin IV’s debt to Venice, culminating in the sack the Liber censuum, a record of papal assets 1184 levy of one bezant per hundredth of of Constantinople by Christian forces. and expected revenues.27 Innocent IV was moveables, two bezants per hundredth of According to Powell, Innocent was mindful the son of an imperial tax collector, and he church, monastic, and baronial revenues, and of both clerical opposition and the failure would raise the rates of taxation in the papal a hearth tax of one bezant (or whatever they of his financial plans in 1199 and sought states.28 Asbridge understood the Saladin could manage) on the poor.12 The revenues conciliar approval for the 1215 tax instead of Tithe in a manner which agrees with Cazel’s were to be collected by bishops.13 declaring it solely on his own authority.21 claim that it represented the best model for Cazel previously demonstrated that Collections for the Fifth Crusade were funding crusades, arguing that it produced the 1185 levy was at a rate of a hundredth dreadfully slow and plagued by obstinate “the peak of a well-financed crusade army”, per moveables, and he concluded that this clergy, and by 1221, six years after the though he pointed out that only England rate was borrowed from the 1184 levy and Fourth Lateran council declared a three had the administrative capabilities to enact extended to cover a period of three years.14 year twentieth, it was still being collected.22 such a tax.29 Bird acknowledged the effect Finally, the Saladin Tithe of 1187-88 was Kay argued that Honorius III, whom Lunt of the crusades as a stimulant on the overall assessed at a rate of a tenth on moveables, blamed for the turn to papal centralization, economic atmosphere of the Middle Ages.30 with the same exemptions as 1185, but actually tried to avoid resorting to it and Overall, scholarship indicates that the with the new stipulation that taxpayers experimented with delegating legatine twelfth century secular levies formed the assess themselves but pay before a mixed lay powers to four French bishops for collection basis for clerical taxation. This history can be and clerical committee to ensure that the of the Albigensian Tenth in 1221. However, traced to the levy of 1166 and the subsequent assessment was honest.15B Not only were he found that in doing so, the collection levies that were built into the Saladin Tithe, elements of ecclesiastic authority present in was hampered by personal vendettas and which became the model crusade tax. The each of these taxes, but the Saladin Tithe local feuds among those bishops, which first general tax on clergy came in 1200, but

41 Journal of Undergraduate Research – Volume X History elements of church authority were present in upon crusade taxation by wielding it for their of the annual parish tithe, to Fernando III the previous secular taxes, and this blending own interests.35 He demonstrated that the as significant in the history of the funding of ecclesiastical and secular elements persisted crusade tenth was used as a primary means of the Spanish wars of the Reconquest.45 He in the policies of Innocent III. Issues arose of funding for the crusade against Frederick argued that in doing so, Innocent IV opened immediately among the clergy and increased II’s son Manfred from 1255-1266, as well as the door for Spanish kings to further levy along with papal centralization of collections, for the initial phase of the War of the Sicilian ecclesiastic incomes for their own purposes.46 though only after other experiments with Vespers. However, the tenth weakened after John France pointed to the cruzada tax, an local collection had failed. Monarchies and 1283 and continued to do so for at least ecclesiastic tax granting minor indulgences the papacy alike sought to cultivate their twenty years with the successive defeats which survived into the twentieth century administrative capabilities, and taxation suffered by papal forces, many of whom were in Spain, as a case-in-point example of was a major venue for developing new crusaders who had sworn legitimate vows.36 secular bureaucracies laying claim to crusade articulations of authority and structures At this point, popes such as Martin IV and taxation.47 of governance. These experiments in fiscal Nicholas IV levied more tenths in order to Just as scholars agree that the secular organization developed as a response to the offset the decline in value, but this proved taxes of the twelfth century inspired papal financial demands of crusades and the cost fruitless.37 By the time of Boniface VIII, taxation, they agree that in late thirteenth of maintaining subsequent possessions in the tenths were being granted to allies outright century, the growth of royal administrative Holy Land. in exchange for help in the Italian crusades.38 capabilities was the impetus for its decline. Housely argued that this was a critical Secular rulers turned to crusade taxes as a III. The End of Secular and Ecclesiastical change which caused secular rulers to regard means of expanding their own revenues. Cooperation the clerical tenth not as a papal subsidy, but The domestic crusades of the thirteenth and In the same manner that papal taxation as a national asset which they could levy at fourteenth centuries show a pattern of royal grew out of secular innovations, the will.39 The growing power of the crown came subjugation of the clerical state and a decline development of the secular state ultimately to subjugate the clerical state, most notably in the returns of crusade tenths. The Saladin led to the devaluation and replacement of when Philip IV, seeking funding for his wars Tithe, in which Cazel believed lay the key to the clerical income tax. . Beginning in the with England, established royal hegemony successful crusade taxation, instead became late thirteenth century, competition between over the tenth in his lands.40 The Avignon the model of the secular income tax. In ecclesiastical and secular authorities over the papacy continued to levy tenths rigorously, England, France, and Spain alike, kings laid right to tax local clergy led to popes levying but they were less important as a source claim to the revenues of the church in their more and more clerical taxes, decreasing of revenue and only caused more clerical jurisdiction, and the clergy emerged by the their effectiveness while also cultivating dissent. end of the thirteenth century with significant more discontent. Lunt argued that secular Boniface VIII attempted to curb economic losses and a strong desire for rulers adopted clerical taxation to augment secular appropriation of the tenth with the reform. their own revenues, and as it became more bull Clericos Iaicos in 1296, requiring papal profitable for them, it became less so for permission before a secular state could tax IV. Crusade Finance as a Policy of Reform the papacy.31 Thus deprived of its primary church revenue. However, Phillip Stump While the connection between secular method of funding crusade enterprises while pointed out that Clement V revoked the bull and ecclesiastic taxation has been fleshed simultaneously faced with more powerful in 1306, and secular rulers had been levying out by decades of academic study on and demanding secular administrations, the tenths constantly since. Stump argued that crusade finance, a more recent development papacy turned elsewhere for financing any reform of clerical taxation was one of the reinterprets the nature of papal fiscal policy crusading endeavors. key points of contention at the Council of itself as it relates to crusading. Lunt and Though he was focused more on the Constance and argued that secular rulers, Brundage wrote that the developments of the development of crusader legal institutions, previously thought to be the champions of legal and financial institutions of crusading Brundage did examine the use of crusade church fiscal reform, actually opposed it, were rife with abuses, and the motivations of tithes by secular rulers. He noted that as they were already able to utilize clerical crusaders and curialists alike came to be seen Edward I began a trend where English kings taxation to suit their needs by the time of the as materialistic.48 However, beginning with levied crusade tithes, but applied their own Council.42 Cazel also argued that political Jonathan Riley-Smith in 1986, scholarship purposes and interests to the use of the jealousies destroyed the cooperation between has indicated that spirituality, not material revenues.32 In other words, money raised in the papal and secular authorities on the issue gain, must be recognized as a key motivating the name of crusading was not supporting of taxation. He pointed to the irony that, factor among crusaders to journey to the the Holy Land. Ultimately, Brundage by the late thirteenth century, secular rulers Holy Land. This method of evaluating argued that legal developments transformed levied crusading taxes for their own uses, the spirituality of crusading as opposed to the crusades into an internal European yet they expected the clergy and the church the material aspects has since been applied institution, and the popes increasingly used to fund them when they did actually go on to the crusade finance, and the resulting the “guise of the crusade” to raise money crusade.43 The Saladin Tithe actually became studies indicate that the thirteenth century for political wars instead of Holy Land the model of taxation in secular states, and fiscal policies associated with crusading were operations.33 As the legal institutions of the the clergy were left as the primary economic reformative in nature. It was the desire to crusade were expanded in canon law, secular losers of the entire crusading era.44 maximize the practicality of crusading for all princes sought to utilize crusader privileges Recent scholarship has only made Christendom, not materialism, which ought for their own purposes. the breakdown of papal and secular fiscal to be recognized as a key motivator for the Over a decade later, Housely would refute cooperation clearer. French monarchs were Curia in regards to clerical taxation. Abuses Brundage’s notion that the papacy was using not the only secular authorities to appropriate came about in practice, but the theory the crusade as an excuse to launch political church revenues to fund their wars. Joseph behind this taxation must be recognized for wars, but he continued to expand on the F. O’Callaghan considered Innocent IV’s its insight on the motivations of participants notion that secular states were encroaching concession of a portion of the tercias, a third in crusades.

Journal of Undergraduate Research – Volume X 42 History

As mentioned, Riley-Smith challenged of Innocent’s programs and muster a “mass not, as thought by Lunt and Brundage, a the status quo of mid-twentieth century mobilization of purses” through redemption purely materialistic act. scholarship which held that the crusades of vows.57 Though Lower’s study proved that Though Riley-Smith initially focused were ultimately motivated by a desire for this policy ultimately failed for Gregory, the on the relationship between spirituality and materialistic gain. He broke new ground belief that a willing laity could be united in crusader motivations, it is logical to examine by utilizing charter evidence to illustrate the participation through a wider availability papal fiscal policies in this way as well. By various motivations of the first crusaders. of the crusade indulgence can be seen as a examining charter evidence, Riley-Smith He argued that crusading was, by nature, theme of crusade taxation throughout the also illuminated the substantial sacrifices an expensive endeavor, requiring up to five first half of the thirteenth century.58 that noncombatants and families were times the annual knightly income.49 Most Bird, Bolton, and Parker have already making to crusading, even from its crusaders went east without hope of financial contributed greatly to the understanding outset. This formed the basis for Innocent gain, and those who returned carried little of the reformative nature of Innocent III’s III’s initiative of mass signing and vow wealth back with them.50 What spoils were policies. Innocent sought to recover lost commutations. When this is applied to the gained were spent almost immediately on revenues and generate new ones in kind image of the early thirteenth century papacy food and equipment, which became ever through a reform of both curial and local as presented by France and Lower, it could more scarce and costly as the expedition parish finances. Crusade and fiscal policy be suggested that such acts as Quia Maior, pushed deeper into the Levant.51 He also were interconnected for Innocent, and he previously seen as cynical fundraising, were disproved the notion that families used sought to use both to return his Church to actually practical extensions meant to both the crusade as a platform to offload their good standing, utilizing vow redemptions as foster support for the crusades and maximize greedy second sons. Riley-Smith pointed a method of extending salvation to as many their salvific effects. Scholars have recently out that families made considerable financial souls as possible.E Innocent also consolidated interpreted Innocent’s policies as being sacrifices to send their sons, husbands, and curial finances, demanding proper census reformative in design and motivation, meant fathers on crusade, mortgaging their own payments and establishing fixed fees for to improve curial finances and cultivate inheritances and receiving little to no profit curial services instead of allowing officials parish revenues while also addressing known as a result.52 Recent scholarship has examined to simply collect gifts. Furthermore, Parker complaints over revenue collections. Whereas papal financial policy through this emphasis noted that Innocent focused on establishing earlier scholars such as Brundage and Lunt on spiritual motivations. effective collection while also legislating saw these developments solely as extensions Riley-Smith’s point on families making against abuses by collectors. Pium et Sanctum of curial power, Bolton, Bird, Smith and financial sacrifices from the outset of required crusade preachers to minimize their Parker have shown that their basis was more crusading indicates that when Innocent III entourages, refuse personal gifts, and live spiritual and practical. Innocent’s fiscal issued Quia Maior in 1215, famously calling frugally so as to embody Christian poverty.59 policy in relation to crusading was grounded on every member of Christendom to take the Ostentatious preachers, the pope concluded, in what he perceived as his responsibility to crusade vow in order to either carry it out were not likely to collect alms from the save as many souls as he could. physically or commute it through donation, faithful, as they did not embody the image he did not do so without precedent. Quia of the Church which Innocent wished to V. The Council of Constance and Maior did not invent the notion that non- project. Indulgences as a Revenue Source combatants should contribute financially Innocent also sought to stabilize local The idea that indulgences were intended to the crusade; it simply formalized an idea parish finances and protect parochial tithes as a source of revenue for the Church is long in gestation among the Curia.53 Non- by eliminating tax shelters, ending exceptions noticeable throughout early twentieth combatants had already been contributing on land acquired by religious orders, and century scholarship, likely derived from financially to the crusade since 1095 and assessing tithes before other dues to ensure contemporary critics of ecclesiastical wealth were doing so without enjoying any crusade that parishes saw increased revenues.60 Bird such as Matthew of Paris. However, more privileges or rewards in return. France and Parker argued that Innocent’s motive recent study has indicated that this is not argued that Innocent was not pursuing in doing so was to provide more revenues the case. Innocent III’s decision to install cynical fundraising, but was trying to extend for local communities, hopefully making mass signing and vow commutation was the salutary effects of crusading to the laity them more likely to participate in taxation. not cynical fundraising, as mentioned as a whole who had already been involved in They concluded that Innocent was mindful previously. The work of historians such as bearing the economic burdens of crusading of public opinion regarding the church and Stump and Bird has shown that indulgences since 1095.54 He posited that Innocent sought to make it more positive, primarily were not sold to generate revenue themselves saw financial support of the crusade as a through financial reform in order to but meant instead to reward donations purifying act, even if it was impersonal.55 stimulate crusade involvement.61 If parishes and enable widespread participation while Commutation of vows was thus seen as a had more revenue in general, they would also ensuring the military viability of the practical extension of crusading privileges be more willing to contribute a portion of army.F It was only after the devaluation of to all Christians, a dual effort on Innocent’s it to crusade by commuting their vow as an the crusade tenth, the widespread taxation part to foster support for the crusade while act of participation, especially if a partial of the Avignon papacy, and the reforms of also offering salvation to as many souls as indulgence was extended to them for doing the Council of Constance in 1418, that possible. Innocent’s successors continued so. Innocent’s fiscal policy was thus dually indulgences came to be treated as “spiritual to refine this policy, culminating in Gregory aimed at facilitating the crusade while revenue”. Indulgences became revenue only IX’s bull Rachel suum videns. In his study of simultaneously offering salvation to his flock after the program of papal taxation was the Baron’s Crusade (1231-1241), Michael of souls.62 Curial and parish finances were handicapped. Lower also considered the idea of Christian reformed in order to stimulate a healthy As mentioned, Lunt treated indulgences unity through crusading to be the primary public perception of the church, and the turn as a source of revenue, and he interpreted the policy of the thirteenth century popes.56 to vow commutation was the most practical tendency of seekers of papal pardon to make Gregory IX, he argued, sought to build off way of involving the laity in crusade. It was offerings in exchange for commutations of

43 Journal of Undergraduate Research – Volume X History their vows as evidence of material motivation success for the reformers. It required not that indulgences were never intended as and papal corruption.63 These offerings only that the Pope notify and meet with the outright revenue by Innocent III or his normally found their way into local church clergy, but he also required their subscription thirteenth century successors. The policy institutions or were sent off with crusaders, before declaring a tenth. Further, a universal which produced the crusade indulgence was but by the 15th century, all receipts from tenth had not been levied since 1343; instead not the same as the policy which produced indulgences went to the papal Camera.64 localized territorial tenths were consistently the indulgences which Luther denounced. What Lunt neglects to mention is how this raised by the Avignon papacy.72 These changes The involvement of crusade indulgences transition occurred. Brundage made a similar demonstrate the growth in representative in financing of crusades was meant to argument, pointing out that the failure of the bodies in response to taxation, but they incentivize the laity to take the cross, give second crusade made it obvious that a method did not indicate a wholesale rejection of alms, and pay taxes. The use of indulgences of participation for the militarily unfit was the validity of crusade taxation. Though as incentives was also not without precedent, needed. However, Brundage believed that this participation was still willing, representative as Eugenius III had offered a 1/7 indulgence decision was motivated by the desire to turn bodies desired a role in dictating the terms of to those who donated to the Second Crusade, enthusiastic noncombatants into a source of potential taxes.H as noted by Collins and Phillips.77 There was income, but he did not consider the spiritual Stump contended that these changes no systemized taxation at this point, and implications of doing so.65 Bird, Bolton, actually limited papal power and effectively payments by the laity toward the crusades and Parker illustrated that spirituality was ended crusade taxation as an important were still entirely optional. Innocent was very much present in the minds of Innocent source of income. As previously evidenced acting on precedent. Gregory VIII gave III and his successors as they made vow by France and O’Callaghan, the cruzada indulgences in return for donations after the commutation into regular policy. Lay non- tax continued, as did others, but these were fall of Jerusalem in 1187, and the strength combatants had been participating in the insignificant. Crusade taxation had been of the indulgence was proportional to the crusade movement from its beginning, both declining in value for the papacy since the late amount given.78 as active pilgrims and by making substantial thirteenth century, and the more significant It is deceptively easy to see this as cynical economic sacrifices to send family members sources of revenue (spoils, annates, and materialism as Lunt and Brundage did, on crusade. They were involved in financially services) were constantly reserved by Avignon but recent studies have raised a powerful supporting the crusades from the beginning, popes to the chagrin of local clergy. This alternative interpretation. Bird and Parker and the extension of an indulgence to them practice was also reformed at Constance, as analyzed Innocent III’s education in Paris in exchange for vow redemption can be evidenced by Stump. Martin V ended papal under Peter the Chanter before he became seen as a means of practical policy that fell reservations of spoils and procurations and pope, which sheds valuable light on how in line with Innocent’s desire for widespread left them to local clergy, and he extended Innocent handled indulgences. Peter the involvement and widespread salvation. the payment of services by an additional Chanter did not approve of indulgences in Stump saw the Council of Constance as year while also reducing the assessment itself theory, but he recognized their practicality the point from which indulgences became a by half.73 This was monumental. Services, to sinners who have no other options.79 source of “spiritual revenue”. He challenged especially in France, were a critical part of Innocent considered them in this same the notion, held by historians such as Hübler papal income, and the reform of Constance vein and treated them as a minor spiritual and Valois, that Constance did not lead to resulted in major losses to papal revenue.74 cost which would result in a significantly reform, and that curialists circumvented It was only after these losses, Stump argued, greater spiritual benefit. The indulgence the desire of the French and German that the papacy turned to “spiritual revenues” of the twelfth and thirteenth centuries was representatives.66 The Council reformed (indulgences) and pressed their seigniorial not thought of as revenue, but as the most both the process of levying tenths and other claims in Italy and became even more effective way to involve the laity in the methods of papal income, notably spoils, embroiled in Italian politics.75 It was only crusade. It was only after crusade taxation annates, and services, which by that point after Constance that the outright sale of was claimed by secular powers, abused by the had overtaken tenths as the primary source indulgences became papal policy. Avignon papacy, and reformed at Constance of papal revenue.67G The German reform According to Collins, the clergy were that the indulgence changed from a practical party wanted to require approval of a general always opposed to taxation, and as the spiritual incentive to an outright source of council before a tenth could be levied, and Avignon papacy continued to levy tenths at revenue. Hübler believed this to be an indication that an increased pace, reserve annates and spoils, Constance represented a movement toward and clamp down on payments of services, VI. Conclusion conciliar authority, resulting in escalating this opposition only increased.76 Thus, By analyzing the scholarship of crusade anti-ecclesiastical tensions when this was coinciding with Stump’s study, it is clear that finance, several trends can be identified, some denied.68 Stump indicated that only a the Council of Constance was not meant to continuous and some recent. Scholars assert small amount of reformers actually wanted be a precursor to the Protestant revolution by that secular taxation in the eleventh century conciliar authority, and even the German attempting to instill a sort of parliamentary was built on adaptation, and subsequent taxes king Sigismund, thought by Hübler to be a authority over the church. Instead, reformers were influenced and shaped by previous ones reformer, would have opposed this move.69 were simply fed up with abuses from papal while also incorporating elements of secular The general council would have met once and secular collectors alike, and they sought and ecclesiastic authority. The success of the every ten years, and requiring its authority only to limit the burden of taxation upon Saladin Tithe inspired Innocent III to turn to levy a tenth would have undoubtedly themselves. In doing so, they created a clerical taxation into papal policy in 1200, destroyed the effectiveness of the tax. vacuum in papal sources of revenue which and here again subsequent taxes were built Instead, Martin V settled on requiring caused the outright sale of indulgences to on the successes and failures of previous consent of territorial clergy for local tenths reach its apogee, and indulgences took on a ones. The historiography is consistent on and the consent of the College of Cardinals nature differing from their crusade financing this point. The papal approach to crusade and prelates for universal tenths.70 Stump applications. finance in the early thirteenth century was argued that this was indeed a considerable Bolton, Bird, and Parker made it clear motivated by practicality and spirituality. A

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growing scholarly interpretation now the papacy can foster a new understanding whose consent was required for many forms of taxation.” exists in which the expansion of papal financial of what these policies were truly intended to Bird, “Financing the Crusades,” 446. policy by Innocent III and his successors achieve. VIII. References through taxation and vow commutation was 1 simply the most feasible way to steer support VII. Footnotes Parker, M. (2017) “Papa et Pecunia : Innocent A. III’s Combination of Reform and Fiscal Policy to crusading efforts and extend salvific benefits Whether the fiscal policies of the Avignon Papacy Finance Crusades.” Mediterranean Historical Review to the laity. These taxes were thus seen by the were the product of greed on the part of individual 32, no. Pg. 6. papacy as a tool of pastoral care. Fiscal policy popes or a changed economic climate as a result of 2Graves, Edgar. (1935) review of Papal Revenues increased secular power is a topic of debate that this in the Middle Ages, by Lunt, William E, Speculum 10, and crusade were therefore tied together in no. 2. Pg. 218-221. an atmosphere of reform meant to touch paper does not seek to answer. This paper refers to such 3Lunt, W. (1934) Papal Revenues in the Middle every corner of Christendom. fiscal policies as “abuses” because they were viewed as Ages. Vol. 1. Columbia. Pg. 72. such by the reformers at the Council of Constance, who 4Ibid, 10. As secular and curial administrations 5 sought to legislate against them and ultimately led to the Brundage, J. (1969) Medieval Canon Law and the matured, cooperation turned to competition. Crusader. UMI. Pg. 187. Kay proved that curial centralization of changes in policy which this paper addresses. For more 6Cazel, F. (1955) “The Tax of 1185 in Aid of the collections was not the outright goal of in-depth discussions of the fiscal policies of the Avignon Holy Land.” Speculum 30, no. 3. Pg. 385. Innocent III or Honorius III, and it only Papacy and the debate surrounding them, see, for 7Ibid, 388. example, Ludwig Von Pastor, History of the Popes Vol. 1, 8Ibid, 385-389. became the norm when other experiments 9Ibid. involving local authority failed. Thomas The Great Schism, Norman Housely. The Avignon Papacy 10Brundage, Medieval Canon Law and the Smith has advocated for a reinterpretation and the Crusades, 1305-1378 (Oxford, Clarendon Press) Crusader, 195-6. 1986, and Daniel Williman, “The Right of Spoil of 11Cazel, “1185 Tax”, 126. of the maligned career of Honorius III 12 the Popes of Avignon 1316-1415.” Transactions of the Ibid. which highlights the responsiveness of his 13Ibid. diplomacy, and his attempts at crusade American Philosophical Society78, no. 6 (1988). 14Ibid. taxation were likewise an authentic attempt B.The method of self-assessment and establishment 15Ibid, 129. 80 of a lay/clerical committee only applied to England. 16Ibid, 135. to respond to external challenges. The 17 In France, where the tax saw significantly less success, Ibid, 148. appropriation of crusade taxation by 18Queller, D., Andrea, A. and Madden, T. (2000) secular authorities is also consistent in the collection was carried out by individual seigneurs upon The Fourth Crusade: the Conquest of Constantinople. historiography, but until Stump’s study, their lay tenants. The tax was resented in France, University of Pennsylvania Press. Pg. 1-3. not enough attention was paid to the effect and Philip Augustus abandoned it after a year. Royal 19Kay, R., (1980) “The Albigensian Twentieth that the Council of Constance had on papal enforcement of the tax was only present in England. of 1221–3: An Early Chapter in the History of Papal C. Taxation.” Journal of Medieval History 6, no. 3. Pg. finance. Stump reversed the assumption Bishops could not absolve an individual from 308. that the failure of the conciliar movement at excommunication in certain cases. This right was 20Brundage, Medieval Canon Law and the reserved for the Papal Curia, and the individual was Crusader, 187. Constance was a precursor to the Protestant 21 meant to make a personal appeal in Rome in order to Powell, J., (1994) Anatomy of a crusade: 1213- Reformation. Instead, he indicated that 1221. University of Pennsylvania Press. Pg. 91-92. papal finances were effectively handicapped have the excommunication lifted. 22Cazel, F., (1989) “Financing the Crusades” in by the Council’s reforms, and it was only D.On the responsive nature of Honorius’ The Impact of the Crusades on Europe. Hazard, H., after losing nearly every other available pontificate, see Thomas W. Smith. Curia and Crusade: Zacour, N., and Setton, K., eds. University of Wisconsin Pope Honorius III and the Recovery of the Holy Land, Press. Pg. 137. source of revenue that the papacy turned to 23Kay, “The Albigensian Twentieth”, 313. the outright sale of indulgences. Prior to 1216–1227, Outremer: Studies in the Crusades and the 24Ibid, 310. this, indulgences were not seen as sources Latin East 6 (Turnhout: Brepols, 2017). On resistance to 25Ibid, 313. of revenue, as Bird and Parker pointed out, taxation during the pontificates of Innocent, Honorius, 26France, J., (2005) The Crusades and the and Gregory, see Jessalyn Bird. “Finance of Crusades” in Expansion of Catholic Christendom, 1000-1714. and Innocent and his immediate successors Routledge. Pg. 106. treated them as a practical way of extending A.V. Murray. The Crusades: An Encyclopedia, Volume II 27Collins, R., (2010) Keepers of the Keys of the salvific effects of the crusade to the laity. (ABC-CLIO: Santa Barbara, 2006) 442-46. Heaven: A History of the Papacy. Phoenix. Pg. 259. E.See Brenda Bolton, “Hearts Not Purses: Innocent 28Ibid. Pg. 263. The abuses which were reformed by the 29 III’s Attitude to Social Welfare.” In Through the Eye of a Asbridge, T., (2012) The Crusades: The War for Council of Constance were not explicitly the Holy Land. Simon & Schuster. Pg. 385-387. connected to the fiscal programs developed Needle: Judaeo-Christian Roots of Social Welfare, edited by 30Bird, J. (2006) “Financing the Crusades” in in the early thirteenth century by the papacy. Emily Albu Hanawalt and Carter Lindberg (Missouri: Murray, A.V. The Crusades: An Encyclopedia, Volume The Thomas Jefferson University Press at Northeast II. ABC-CIO: Santa Barbara. Pg. 442-46. A line of connection should not be drawn 31 Missouri State University, 1994) 123–145, as well as Lunt, Papal Revenues, 76-7. between Innocent III’s and his successors’ use 32Brundage, Medieval Canon Law, 187. of indulgences for funding crusades and the Bird, “Peter the Chanter’s Circle” and Parker, “Papa et 33Ibid. liberal distribution of indulgences adopted Pecunia.” 34Ibid. by Leo X. Far from being a cynical cash F. On the role of commutation and lay participation, 35Housely, N., (1982) The Italian Crusades: The see Jessalynn Bird. “Vows” in A.V. Murray. The Crusades: Papal-Angevin Alliance and the Crusades Against grab, the financial programs instilled by the Christian Lay Powers, 1254-1343. Clarendon. papacy in the early thirteenth century were An Encyclopedia, Volume IV (ABC-CLIO: Santa Barbara, 36Ibid, 178. built on a mix of spirituality, practicality, 2006) 1233-1237. 37Ibid. G.Spoils refer to the moveable property of deceased 38Ibid. and reform. The intention was to involve as 39 or intestate clerics. Annates refer to a payment to Ibid, 200-1. many Christians in the crusade as possible, 40Ibid. not for the good of the papacy, but in the the Curia from a recipient of an ecclesiastic benefice. 41Stump, P., (1989) “The Reform of Papal Taxation public interest of Christendom as a whole. Services refer to the payment to the curia in return for at the Council of Constance (1414-1418).” Speculum use of the papal chancery. 64, no. 1. Pg. 76. Just as Riley-Smith’s focus on spirituality 42 H.“Levies for various crusades also contributed to Ibid. fostered a new movement in crusader studies, 43Cazel, “Financing the Crusades”, 129. a continued examination of the spiritual the development of centralized financial administrations 44Ibid, 149. motivations and justifications behind the and the growth of papal and royal taxation, at the same 45O’Callaghan, Joseph., (2013) Reconquest and methods of crusade finance employed by time aiding the development of representative bodies Crusade in Medieval Spain. University of Pennsylvania

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Press. Pg. 122. 46Ibid. 47France, The Crusades and Christendom, 303. 48Brundage, Medieval Canon Law, 135-6; Lunt, Papal Revenues, 115. 49Riley-Smith, J. (1986) The First Crusade and the Idea of Crusading. University of Pennsylvania Press. Pg. 43-47. 50Ibid. 51Ibid. 52Ibid. 53Smith, T.W. (2019). “How to Plan a Crusade Call: Pope Innocent III and Quia maior (1213).” Historical Research, volume 92, issue 255. Pg. 7-8. 54France, The Crusades and Christendom, 160- 163. 55Ibid. 56Lower, M., (2005) The Barons Crusade: A Call to Arms and Its Consequences. University of Pennsylvania Press. Pg. 16. 57Ibid. 58Bird, J. (2003). “Innocent III, Peter the Chanter’s Circle, and the Crusade Indulgence: Theory, Implementation, and Aftermath.” In Innocenzo III: Urbs et orbis, atti del Congresso Internazionale (Roma, 9–15 settembre 1998) [Innocent III: City and World, Acts of the International Congress (Rome 9–15 September 1998)], edited by Andrea Sommerlechner, vol 1. Rome: Società romana di storia patria. Pg. 509. 59Parker, “Papa et Pecunia”. Pg. 7; Bird, “Peter the Chanter’s Circle”, Pg. 509. 60Ibid, 10. 61Bird, “Peter the Chanter’s Circle,” 509. Parker, “Papa et Pecunia”, 12. 62Bird, “Peter the Chanter’s Circle”, 509. 63Lunt, Papal Revenues, 112. 64Ibid. 65Brundage, Medieval Canon Law, 75. 66Hübler, B., (1867) Die Constanzer Reformation und die Concordate von 1418 B. Tauchnitz, Pg. 360- 388; Valois, N., (1896) La France et le Grand Schisme d’Occident, Vol. 4. A. Picard. Pg. 419-426. 67Lunt, Papal Revenues, 93-9, 103-7, 126. 68Hübler, Die Constanzer Reformation und die Concordate von 1418, 360-88. 69Stump, “Reform of Papal Taxation”, 104. 70Ibid, 73. 71Ibid. 72Ibid, 72. 73Stump, “Reform of Papal Taxation,” 98. 74Ibid, 72. 75Ibid, 105. 76Collins, Keeper of the Keys of Heaven, 350. 77Collins, 6. See also Phillips, Jonathan. The Second Crusade: Extending the Frontiers of Christendom (New Haven: Yale University Press, 2010). Pg. 106. 78Parker, “Papa et Pecunia”, 6. 79Ibid. See also Bird, “Peter the Chanter’s Circle,” 506-8. 80Smith, T.W. (2017). Curia and Crusade: Pope Honorius III and the Recovery of the Holy Land, 1216– 1227, Outremer: Studies in the Crusades and the Latin East 6. Turnhout: Brepols.

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