Flying off the Wagon

Matt Freeman
2 February 2018

Alex Hunter and Paul Papadimitriou are hosts of the Layovers podcast. They review and discuss air travel from a wide array of perspectives: from politics, to economics, to vomit-covered seats (a flight attendant advised Alex that it was chicken curry, not vomit, so he need not be concerned.)

I encourage those who fly and who enjoy learning more about one of the most complex industries imaginable to listen to their podcast. Paul and Alex inspired me with a challenge to write more, including the relationship between health and flying, and what I see in everyday clinical practice.

 

The former patients discussed in this article are real; their names are pseudonyms.

 

Robert shifted in his chair. His blood pressure was a bit higher than normal, his complexion ruddy, and his eyes were somewhat bloodshot. I had already seen his blood work. Two of his liver enzymes were above normal, the average size of his red blood cells was higher than what one might expect. It was hardly a diagnostic conundrum. The 52-year-old man in my office was almost certainly an alcoholic.

I followed a careful, nonthreatening path in our conversation. I asked about sleep, stress, depression, and finally alcohol. He evaded the topic by saying he was a “social drinker.”

In a somewhat sneaky but effective maneuver, I examined his liver. As I let my hand slip beneath his right lower ribs, I asked, “Do you find yourself drinking more than you should?” It was as if he thought I could feel the bottle caps and wine corks in his abdomen. “Yes,” he replied. “I mean a lot.”

Once he was off the exam table and we could talk face to face, Robert assured me that he would never drink on duty. And he would never violate the 12-hour “bottle to throttle” rule. He is a captain, flying Airbus jets for one of the largest airlines in the world.

He had little difficulty “passing” his routine medical examinations to keep his license. He knew which medical examiners would ask the fewest questions, thereby ensuring that both the doctor and the pilot would maintain job security.

Stripes

“So many of us drink.” Robert was sullen. “You’re alone in some hotel room. There is no way to unwind. It just becomes a habit. More than a habit.”

Robert is not alone.

Air travel and alcohol abuse have a longstanding partnership. Higher-risk drinking has been described as a “silent epidemic” among passengers and crew alike.

The liquor culture of air transportation is due in part to economics.

During the 1970s, airfares on US airlines were regulated by the Civil Aeronautics Board. Since the airlines could not compete on price, they competed with service. Alcohol was often cornerstone of competition. Jumbo jets were fitted with bars in both economy and first classes, Delta Air Lines began offering complimentary champagne, and National Airlines offered complimentary alcohol of any kind. Eastern Air Lines described complimentary alcohol as “unconscionable,” but market forces drove them to offer free booze as well.

American Airlines pioneered the Bloody Mary. Viewed as a socially acceptable cocktail for the morning, passengers consumed the vodka-laced tomato juice with zeal. American reportedly turned the bottlers of Mr. and Mrs. T. Bloody Mary Mix into millionaires.

Bloody Mary

Mechanics at American noticed that some of their planes were sustaining daily gouges to their cabin walls. The source of the damage turned out to be from bar carts jamming into the wall. The crew were serving liquor so early during a flight’s ascent that they could only stop the carts effectively by letting them jam into the wall.

In 1972, Southwest Airlines engaged in an airfare war with a competitor. Passengers were offered the opportunity to purchase a ticket for $13 or pay $26 for the plane ticket and receive a bottle Chivas Regal scotch whiskey. More than three quarters of the passengers chose to pay double and buy the bottle of whiskey as well as the plane ticket, making Southwest the largest distributor of Chivas in Texas.

chivas

In the post-deregulation era, alcohol continued to serve as a selling point. Airlines compete by offering complimentary liquor. In business and first classes, air carriers feature sommeliers, who have selected finer wines for their higher-paying guests. On the ground, open bars welcome passengers in airline lounges. Industry consultants have noted that passengers will sometimes select an airline based on its liquor policy.

Forty-four years after its free Chivas offer, Southwest Airlines was still unabashed by its promotion of tipsy flying. Passengers on a three hour, twenty-minute flight from Oakland to Kansas City earned an announcement of congratulations from the captain. The passengers had emptied out all of the bar carts on the airplane.

The “high life” of champagne and Scotch whiskey above the clouds can often have a dark side.

Hugh, 52, travels for 40 weeks per year. As a salesperson, he dines out at least three nights per week. At sales dinners, he typically has a few glasses of wine followed by a few glasses of Scotch. That is three times the recommended alcohol intake from the Centers for Disease Control and Prevention (CDC) guidelines. When Hugh boards a flight to his next destination, he usually has a Scotch prior to takeoff, and wine, beer, or whiskey in flight based on the length of the flight.

Although he came to see me for a routine physical exam, Hugh conceded that he is unhappy with his life.  He is frustrated by his weight, poor sleep, lost sex drive, and lack of emotional connection to his wife. Unlike Robert, Hugh was not ready to talk. He never returned to have his blood drawn. I suspect he will find a primary care provider who will ask fewer questions. Perhaps he will just forego seeing a doctor entirely.

Frequent flyer like Hugh, the so-called “mobile elite,” can be predisposed to problematic drinking. Studies of the frequent flyers have yielded a profile of passengers who socially isolated. While flying around the country or the globe, passengers like Hugh may lack the opportunity to engage in collective activities, and they may have frayed friendships. Relationships can become unequal: the frequent traveler may be away so often that he or she cannot participate equally in household chores, child-rearing, etc. Despite higher incomes and access to healthcare, this population is not in good shape.

TagsIn some respects, the airlines enable Hugh and travelers like him. Catherine, 41, pours Scotch for passengers like Hugh. Catherine has been a flight attendant since she was 21. With two decades of seniority, she often finds herself rostered for her favorite trips: business class to Frankfurt. I met Catherine after an accident that occurred while she was off duty. She fell on the steps outside her apartment. Her blood alcohol content was 0.18 percent when it was measured in the emergency department. (Loss of consciousness can start at 0.2 percent; death at 0.5 percent.)

Dodging questions about alcohol, Catherine laughed as she describes her recipe for “crew juice.” This is a nickname for a punch made of any variety of combinations of liquor pilfered from the bar cart. Binge drinking—with “crew juice” or another source—is part the routine.

Getting drunk is not just an accident; it is an expectation.

Tina, 50, a senior flight attendant, complained that her employer sometimes lodged its crews in the same hotels as its passengers. “We can’t get drunk at the hotel bar,” she complained. Getting drunk, as far as Tina was concerned, was part of the itinerary.

Amanda Pieva, a journalist and flight attendant, wrote of the silent epidemic of alcoholism among crews. “We drink to help ourselves sleep when work disrupts our body clocks, and we drink when we run into long lost friends on our travels. While social drinking is the norm in society as a whole, it is amplified in the airline industry.”

Pieva continues, “The industry creates many alcoholics, most of whom are functional.” Since alcoholism is so widespread, Pieva argues that it has been normalized, and therefore not a topic of discussion.

Minis

Although Catherine appeared to be in denial, her drinking habits were unexceptional in her environment. Data from airline pilot surveys have shown that crews do not necessarily have a greater prevalence of alcoholism than the general population, but they tend to over-estimate the number of drinks required to become intoxicated. There was no pattern related to the type of aircraft flown nor the number of years of experience.

Pieva wrote, “Every single pilot or flight attendant I’ve talked to about this with adamantly agrees that alcohol abuse is a silent epidemic among us.”

The consequences of the silent epidemic are both short- and long-term, affecting both crew and passengers.

  • In 2016 security staff smelled alcohol on a United Airlines pilot at Glasgow. A blood test taken two hours after his removal from the flight showed blood alcohol content more than double the upper limit.
  • In 2013, a Pakistani pilot was imprisoned in the UK. His blood alcohol content was more than three times the normal limit He confessed to drinking three-quarters of a bottle of whiskey prior to the flight.
  • In 2002, two America West pilots were ordered to taxi back to the terminal. Both were convicted of drunk flying.
  • Alcohol was implicated in two fatal accidents in the former Soviet Union in 2011 and 2012.

Intoxicated passengers can pose a danger to themselves and others. In at least one documented instance, a passenger died during an otherwise survivable aircraft evacuation. His blood alcohol content was 0.24 percent. He had not even unfastened his seatbelt. the passenger who died was only one fatality. His alcohol-induced incapacitation could have easily impeded the evacuation of other passengers and crew.

A BAC of 0.24 percent is the equivalent of about ten drinks in a 160-pound man. If that seems like a lot, one investigator was served 12 drinks during a 90-minute flight.

The rise in “air rage” incidents is multifactorial, but alcohol has been implicated in at least 45 percent of reported disruptive passenger incidents. These disruptions can range from quiet disregard for safety to diversion of a flight. Surveys of airline passengers found that those who stated that they intend to consume alcohol on board were twice as likely to agree to the statement, “I rarely or never wear a seatbelt.” In more extreme circumstances, intoxicated passengers have engaged in obscene behavior, destroyed aircraft equipment, and threatened the safety of passengers and crew.

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Passenger misconduct is widely deemed to be under-reported. An estimated one in 140,000 passengers engage in some form of misconduct per year. Up to one in a million are reported to have been involved in serious misconduct. This appears to be statistically infrequent until one considers that 650 million passengers fly annually. That is 650 cases of severe misconduct per year, and a little fewer than half of those cases have an alcohol component. At minimum, that is just under two serious alcohol-related misconduct incidents per day.

The risk persists after landing. In 2006, a passenger boarded a flight already intoxicated. He then purchased and drank two Jack Daniels “minis” on board a flight from Phoenix to Albuquerque. After landing, he drove from the airport, killing five in a motor vehicle crash. He died some hours later with a blood alcohol content of 0.32 percent.

Travel has been described as “situational disinhibition.” Airline passengers might engage in behavior that would otherwise seem uncharacteristic.

Alcohol itself reduces inhibition, and the combined forces can mean that passenger are less guarded. Binge drinking can be the start of a cascade of health-compromising behavior.

Studies of international travelers found that 20 percent of international travelers engaged in casual sexual relations while abroad. This applied to all types of travelers (business, leisure, family). A study of Belgians working overseas found that 51 percent of male workers had extramarital sex with local women, 31 percent with a commercial sex worker, and only 25 percent of almost 2,000 men in the study reported using a condom.

Alcohol intensifies the risk. Women who binge drink are five times more likely to contract gonorrhea, and report more sexual partners than women who consume alcohol in moderation.

The combined disinhibition from alcohol and the air travel environment can catalyze violence.

Sara Nelson, president of the Association of Flight Attendants, cited a lack of cabin staff, dark quarters, and alcohol as factors that can lead passengers to commit sexual assault. Although the proclivity to commit such an offense might exist on the ground, the aircraft cabin or the hotel away from home can provide the environment and the opportunity.

Onboard assault cases are hard to track: some are reported to local police, some to the FBI. The FBI reported 40 investigations opened in 2015, 58 investigations during the first half of 2016. The FBI acknowledges that about 75 percent of assaults are unreported.

There is no single tracking mechanism for inflight assaults, and flight crews do not receive training in the management of these situations. The crew have the burden of reporting disruptive behavior, but there is no box to tick for sexual assault.

Furthermore, reporting can be abbreviated or lost on international flights, where foreign law enforcement officials are involved.

Hooters AirDefunct Hooters Air: the ultimate combination of sexism, alcohol, and flying.

Flight attendants who have been assaulted are often unwilling to report the crime, “They’re not going to stop the plane. And then everyone’s going to be mad at you; you’re not a team player, you’re difficult” stated former flight attendant and assault victim Lanelle Henderson.

Henderson and others described assaults not just by passengers but by other crew members. Stories of intoxicated pilots assaulting flight attendants are common but rarely reported.

Male crew are not exempt from harassment. A flight attendant for JetBlue described frequent unwanted comments about the “Mile High Club,” and being grabbed or touched inappropriately by male and female passengers.

Sara Nelson described the notion that passengers can feel “out of the public eye” and therefore somehow get away with abusive behavior that they would otherwise eschew. The disinhibiting effects of alcohol combined with an altered sense of self can lead to behavior that can range from indecorous to criminal

Nelson described a conversation overheard by a coworker:

“When can we get some drinks around here, honey?’” asked several male passengers. While the flight attendant was still in earshot, “You can probably get sued for calling someone ‘honey’ nowadays.”

Although one could argue that these passengers could be chauvinists without alcohol, one can assume that alcohol diminishes or silences their superegos. In a service industry in which “the customer is always right,”  passengers under the influence may feel somehow more entitled to be verbally or sexually abusive.

There is little incentive from the air transportation industry to restrict alcohol sales and consumption. In fact, restriction can affect profits. Irish low-cost airline Ryanair requested that airports limit alcohol to two drinks per person, and that airports ban serving alcohol before 10:00 am. Another low-cost carrier, Jet2 of the UK, stopped alcohol on morning flights.

Ryanair

Passengers resented the restrictions, claiming that the airlines had ruined their holidays. As one passenger put it, “Unless you’re being rowdy there’s no need [for a crackdown.]”

Airports that were affected by Ryanair’s restrictions claimed that the air carrier was really just attempting to increase its own inflight liquor sales. Moreover, airports depend on alcohol-mediated disinhibition to boost retail and duty free sales.

The duty free shop also provides a method to circumvent airline restrictions. Airline companies are reportedly inconsistent in their enforcement of company policies banning the consumption of alcohol that is not served by the airline crew. Passengers can stop by the duty free shop, even purchasing small liquor “minis” and secret them in their hand baggage for inflight consumption.

DutyFree

On flights with complimentary liquor, or in first and business class, there can be outcry from passengers who feel entitled to maximize their intake. First class passengers on American Airlines began tracking whether or not they were offered the alcoholic drink of their choice before the airplane had pushed back from the gate. They scorned flights in which they were offered water or orange juice, even though the flight had not even taken off. American had to post reminders to its crews to offer passengers their own (usually alcoholic) choice of drinks.

Robert did well. The last time I saw him he had been sober for close to a year, he was taking antidepressants, seeing a therapist, and feeling much healthier. But what about his coworkers who have not sought care? What measures can be taken for passengers and crew members to mitigate the “silent epidemic?”

Given the profits from serving liquor, airline companies and airport owners are unlikely to engage in meaningful efforts to encourage responsible drinking. There are no simple answers to curtail the epidemic and its consequences. At least a few interventions could incite a larger social movement.


1. Educate

There are a wide variety of web sites and magazines devoted to leisure and business travel. These are often found in airport lounges, hotels, or delivered to the homes of some credit card recipients.

Articles about quantifying alcohol intake, understanding limits, and recognizing problematic or addictive behavior could be both interesting and useful to readers.

Print and internet media could also offer lists of resources, such as Alcoholics Anonymous, therapists and addiction specialists may wish to advertise, there could even be support from organizations such as Mothers Against Drunk Driving (MADD).

For crew members, a review of blood alcohol content, the risks in the air and on the ground, and skills for working with intoxicated passengers and crew should be a part of initial and recurrent training.

Likewise, the airlines and their unions should reinforce alcohol abuse as a public health issue over a disciplinary concern so that those affected may be more like to seek help.

2. Include Airports, Lounges, and Hotels in Interventions

Since alcohol served on the ground before, during, and after flights contributes to the epidemic, those serving alcohol should be educated on polite but effective techniques for intoxicated patrons, such as “Distract, Delay, Dilute, and Deny.”

3. Institute Bystander Training for Airline Crews

In response to Title IX lawsuits pertaining to sexual assault on college campuses, many colleges and universities have introduced “bystander training.” These brief courses encourage confidence to intervene. As Lanelle Henderson described above, there is a fear that one could be “not a team player” or “uncooperative.” Bystander Training efforts could embolden crew members to intervene with respect: a quiet reminder that a fellow crew member has had enough to drink already.

Bystander training can also help curtail sexual assault among crewmembers. A crew member who has undergone bystander training may feel more comfortable telling a colleague that it is unwise to go to a hotel room alone, particularly if one or both have been drinking. The goal is to make such interventions expected as part of a community rather than a shock of assertiveness.

As a culture of respectful intervention grows, crew members may become more adept at intervening with intoxicated passengers.

4. The relationship between travel, alcohol, and sexually-transmitted diseases warrants attention and education.

Passengers and crew members deserve to know their risks for sexually-transmitted infections, and they deserve opportunities to learn about how to be screened, and how to protect themselves. Airlines and unions as well as travel web sites and magazines should address the sexually-transmitted disease epidemic and offer recommendations for healthcare providers and clinics that offer screening and treatment.=

For travelers and crew members also deserve evaluation for pre-exposure prophylaxis for HIV (PrEP). Those who have frequent unprotected sex with multiple partners, especially while traveling, and particularly those with a history of one bacterial sexually-transmitted infection, should be assessed for eligibility to take PrEP. This is a safe and effective means of preventing the transmission of HIV.

Condoms should be sold at airport retail outlets, and they should be available in crew lounges.

Condoms

Some airports offer on-site medical clinics. Whenever possible, these clinics should be able to offer sexually-transmitted disease screening and treatment, post-exposure prophylaxis (medication for those who may have been exposed to HIV), and levenogestrel (“Plan B,” an emergency contraceptive or “morning after pill.”)


5. Women traveling alone deserve the opportunity for additional guidance and support.

Although both men and women can be affected, women traveling alone face specific vulnerability. Special efforts should be made to encourage responsible drinking, and how to seek help if one feels threatened—even if the threat seems benign. Passengers can slip notes on napkins to flight attendants, write messages on their mobile devices and show them to crew members, or speak to another passenger if the crew are not available.

Women’s magazines and web sites should offer constructive tips and advice for drinking with caution and avoiding higher-risk situations that could lead to a sexually-transmitted infection or sexual assault.

6. Provide Help Nearby
Most airports have interfaith “chapels.” For frequent flyers struggling with alcohol abuse, it would be wise to offer Alcoholics Anonymous meetings in these spaces. Although the timing may not suit everyone, an AA meeting could provide a safe alternative to the airport bar or airline lounge.

Employees might be too ostensible as they are amid coworkers and in uniform. Alcoholics Anonymous could have chapters near airports, or near areas where there are large or multiple crew hotels.

 

Liquor is a part of life. It is a part of traveling. Drinking can often be fun. I will have a drink (sometimes two) on a plane. But the prevalence of high-risk drinking surrounding air travel is far too dangerous to keep silenced.

Departure board

 

References

Centers for Disease Control and Prevention. Alcohol and Public Health. http://www.cdc.gov/alcohol. Retrieved 21 January 2018

Cohen S. and Gössling S. A darker side of hypermobility. Environment and Planning. 2015; 47, 8

Dickinson G. The truth about drunk pilots – does the profession have an alcohol problem? The Telegraph. 24 January 2018

Feldman J. For Flight Attendants, Sexual Assault Isn’t Just Common, It’s Almost a Given. The Huffington Post. 22 November 2017.

Girasek DC & Olsen CH. Airline passengers’ alcohol use and its safety implications. Journal of Travel Medicine. 2009; 16: 311- 316

Gollan D. Seinfeld Redux: Are American Airlines Flight Attendants Saying ‘No Drinks for You’ in First Class? Forbes. 14 January 2016.

Halliday J & Topham G. Air passengers react to alcohol crackdown: ‘Get as many in as you can.’ The Guardian. 25 August 2017.

Hitt A, Ireland DR, & Hoskisson R. Strategic Management: Competitiveness & Globalization. Boston. Cengage Learning. 2017.

Hutton H., McCaul M., Santora P, Erbelding E. The relationship between recent alcohol use and sexual behaviors. Alcohol Clin Exp Res. 2008; 32, 2008-2015.

Modell JG and Mountz JM. Drinking and flying – the problem of alcohol use by pilots. The New England Journal of Medicine. 1990; 323: 455461.

Petzinger T. Hard Landing. New York: Times Books. 1995.

Pieva, A. The Airline Industry’s Drinking Problem. News Limited. 2017

Plush H. Pilot ‘congratulates passengers’ for drinking all of the alcohol on board. The Telegraph. 12 December 2016.

Schwartz K. Recent Incidents Put a New Focus on Sexual Assault on Airplanes. The New York Times.  20 October 2006.

Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. International Journal of Infectious Diseases. 2010;14(10):e842–51.

Ward B. Travel and sexually transmitted infections. Journal of Travel Medicine 2006; 10.

©2018

All images labelled for commercial reuse

 

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Squeezed: Four Decades of the Juice Myth

Matt Freeman DNP, MPH

Tamara

I used to live down the street from a juice stand named “Tamara.” The juice was mouth-watering: whatever combination you could imagine. The passion fruit had a perfect tang, the grapefruit was sour, the oranges were ripe and sweet. Situated at the corner of Dizengof Street and Ben Gurion Boulevard, “Tamara” was the ideal location in Tel Aviv. It was easily accessible en route to the beach, on the way back from the beach, or while out for a stroll.

“Don’t you wish we invented, Tamara?” asked my friend, Ariel. “They just have a shack, some fruit, and they hire good-looking students to serve up the juice for the equivalent of US $6.

Ariel and I would chuckle at the juice bar across the street, which was staffed by a schlubby guy. He ne never had any customers. The Tamara brand exuded refreshing youthfulness.

Tamara never claimed to be anything but a juice bar. They served juice that tasted good; just a refreshing treat. They offered no illusion that they were serving some sort of magical elixir. To my knowledge, Tamara does not serve wheat grass.

An acquaintance, Nadav, made an odd claim about Tamara. “It’s a good place for smokers,” he explained. “They need the anti-oxidants so they do not get cancer.” Although not a smoker himself, quitting smoking did not seem to be on Nadav’s radar as a disease prevention strategy. And that’s when I started to think more about juice.

 

“I’ve gone back to juicing.”

I greeted one of my patients recently, and I asked how he had been feeling. “I’m in much better shape. I’ve gone back to juicing.” Paging Nadav.

In fact, many have embraced versions of Nadav’s scientific misconceptions. Oprah Winfrey, Mehmet Oz, Gwynneth Paltrow, and others have extolled the virtues of “juicing” as the key to a healthy weight and a healthy life. Forget flu vaccine, hand washing, seatbelts, or other self-explanatory measures to protect one’s health. The answer lies in juice.

Where does this appeal come from? Why has it been so sustainable?

Juice and Cleansing

Juicing—retail or homemade juice consumption—is frequently associated with the notion of “cleansing.” There are pervasive references for the need to cleanse the liver and colon.

Amid other functions, the liver converts fat-soluble toxins into water-soluble versions, which can be tossed into the colon via bile or into the kidney for excretion in urine.

The colon removes water and absorbs some nutrients, particularly vitamin K, B12, thiamine, and ribovlavin.

The liver and colon do this regardless of what one eats or drinks. In fact, the concept of “detoxifying” the liver is not a possibility. The liver itself detoxifies, so it cannot be detoxified by an external source.

Catherine Collins, a National Health Service dietitian at St George’s Hospital in London put it best. “It’ll probably give you a chance to reassess your drinking habits if you’re drinking too much. But the idea that your liver somehow needs to be ‘cleansed’ is ridiculous.”

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The liver would actually be dysfunctional if it were to be detoxified.

Cleansing advocates argue that toxins accumulate and line the interior of the colon. Moreover, these invisible toxins are weight-bearing and cleansing therefore leads to weight loss.

This is false. The colon is actually full of perhaps trillions of microbes: bacteria, fungi, and protozoa. In fact, the bacteria in the colon serve to produce a small but significant proportion of vitamins.

Bowel obstructions can form from a variety of sources, but this is really just a version of constipation: not an accumulation of “heavy toxins.” A total detoxification of the colon would be disastrous in terms of eliminating beneficial bacteria (so called “normal flora.”) Microbes, by definition, are “microscopic,” and so they just cannot be large enough to contribute to body weight.

 

The Origins of Fruit- and Juice-Based Diets

According to restaurant analyst Andrew Freeman, the most significant introduction of juicing in popular culture was the Beverly Hills Juice Club in 1975. (I know Andy Freeman. He is a great guy. But we are not related—at least as far as we know.) Coincident with a resurgence of American “vitamania” in the late 1970s, juice became allied with the notion that it is a gateway to missing nutrients, and thus a ticket to better health.

The Beverly Hills Juice Club also shortly predated the “Scarsdale Medical Diet,” introduced in 1978. A bestseller, the Complete Scarsdale Medical Diet was the first “ultra low calorie diet.” Although not juice-specific, the Scarsdale Medical Diet permitted “sliced fruit: as much as desired.”

 

The Complete Scardsale Medical Diet

The Complete Scardsale Medical Diet was the invention of Herman Tarnower MD, a cardiologist. Whether deliberate or not, Tarnower’s low-carbohydrate, low-calorie, but fruit-permissive diet was remarkably reinforcing. Diet followers enjoyed significant weight loss at the beginning of their adoption of the diet plan. It is, in fact, the same technique used by pretty much any popular diet: caloric restriction. By swapping half a grapefruit for a meal, Scarsdale dieters were limiting themselves to fewer than 1,000 kilocalories per day.

The body responds with as one might expect in a state of starvation: it digs into energy stored as glycogen. Glycogen itself is connected to water, so there is a substantial fluid loss during the first week or two. The grapefruit or unlimited sliced fruit are not magic: it is just fluid loss.

One of Tarnower’s diet followers was his girlfriend, Jean Harris. Headmistress of the Madeira School in McLean, Virginia, Harris was losing extra pounds on the Complete Scarsdale Diet.

There was one additional element that “completed” the diet: amphetamines. Tarnower was prescribing speed for Harris, which undoubtedly led to further weight loss. The drugs also contributed to her shooting Tarnower to death in 1980. (Not to name drop again, but Jean Harris and I grew up on the same street.)

Over the coming decades, various reincarnations of The Complete Scarsdale Medical Diet surfaced. All of them followed the same caloric restriction model.

Fruit and juice, however, came to the forefront with The Beverly Hills Diet.

 

The Beverly Hills Diet

Introduced in 1996, the Beverly Hills Diet was another bestseller. The diet was the invention of Judy Mazel, who had no formal education or credentials in nutrition or the health sciences.

The first ten days of the Beverly Hills Diet are limited to fruit. The diet actually encourages diarrhea, claiming that it is a sign that the diet is working. Just like the others, the fluid loss from diarrhea provides an immediate—but not sustainable—weight loss. The starvation-based approach of The Complete Scarsdale Medical Diet seems benign in comparison with a diarrhea-based diet. According to the World Health Organization, diarrhea is the seventh leading cause of death worldwide (1.5 million deaths per year.)

I cannot help but recall my friend Kristen’s stories from med school. She had gone on some sort of educational program to Ecuador. She referred to a particular item at the breakfast table as “diarrhea juice.”

The Beverly Hills Diet later gave way to the Atkins, South Beach, and Paleo diets, all of which are variations on the caloric restriction theme.

 

Juice as a Nutritional Superpower

The combination of fruit-based diets and the Beverly Hills Juice Club evolved into the idea of “juicing.” This became an accessible option as household juicers became more affordable and retailers began selling wider varieties of juice combinations. Pomegranate/açai/blueberry smoothies are available at convenience stores. A countertop juicer sells for under $50.

No longer the domain of the Beverly Hills Juice Club, “juicing” became an option for everyone.

Authors of diet books were quick to capitalize on the availability of juice. One name emerged above all others: Joseph Mercola DO.

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Dr. Mercola and the Juice Miracle

On his web site, http://www.mercola.com, Joseph Mercola extols may benefits of juice, particularly how it is preferable in comparison with whole fruits and vegetables. Mercola claims that juice is preferable because, “most people have impaired digestion as a result of making less-than-optimal food choices over many years.” Mercola does not explain the pathophysiology behind his claim: would French fry consumption in the past lead to an inability to digest a banana?

Mercola’s argument is that juice permits one to “pre-digest” nutrients thereby facilitating their absorption. The notion of “pre-digestion” plays upon the same idea that previous dietary indiscretions are irreparable, and that one must consume nutrients in liquid form only.

Mercola has some particularly bizarre claims about juice. He states that it increases energy by “optimizing” the body’s pH. The acid/base balance in the body is complex and constantly adaptive system. The stomach’s buffering mechanisms allow juice to remain acidic in the stomach, but this does go beyond the stomach. If the stomach could not buffer juice, our bodies would be in miserable acidic states. Optimal pH is maintained by the body regardless of what one eats or drinks.

Mercola’s acid/base claim connects with his even more curious assertion that juice provides the body with “structured water,” and “living water.” In an insult to those who have studied the most basic chemistry class, Mercola explains that juice comes as H2O2 not H2O.

H2O2 is hydrogen peroxide. If one were to drink it, it just turns to foam, and eventually just to water. Water does not come in living or structured forms; water is always one oxygen atom and two hydrogen atoms.

 

Juice and Immunity

Mercola argues that juice “supercharges” the immune system, implying that a hyper-responsive immune system is favorable.

Immunity actually only comes two ways: deficient and adequate. There is no “supercharge” to the immune system. In fact, an inappropriately responsive immune response occurs in autoimmune diseases, in which the body attacks itself. These include systemic lupus erythematosis, scleroderma, Hashimoto’s thyroiditis, and others. The “supercharge” is to one’s detriment. Allergies, for example, a result of a “supercharged immune system.”

Commercial juice retailers are a bit more subdued. Jamba Juice argues that its Zinc and Antioxidant Boost “helps support your immune system” with a footnote, “These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease.” Tropicana omits the disclaimer, stating that an eight-ounce glass of its orange juice, “helps to support a healthy immune system.”

The only plausible way to argue “immune system support” from orange juice is that one might be spared from getting scurvy.

Mercola has a strange an futuristic explanation: “…juice supercharges your immune system” with “phytochemicals and biophotonic light energy.” I do not even know how to respond to that other than by asking, “what?”

Beet_juice-01

An antioxidant “boost” is not just dubious, it is dangerous. Nadav’s “smokers need juice” theory is problematic because antioxidants can actually exacerbate lung cancer and increase the risk of death from cardiovascular disease. Antioxidants were long believed to reduce certain activity on the surface of cancerous cells. It seemed like a good idea until the Carotene and Retinol Efficacy Trial (CARET), in which people who were at high risk for lung cancer (smokers, those with a history of asbestos exposure) were given beta-carotene supplements. The CARET trial stopped before its planned end date because those participants who received antioxidant supplements had more cases of lung cancer. (Sorry to break the news to Nadav.)

 

Juice and Alzheimer Disease

Mercola states on his web site, that juice can “Support your brain health. People who drank juices (fruit and vegetable) more than three times per week, compared to less than once a week, were 76 percent less likely to develop Alzheimer’s disease, according to the Kame Project

On the surface, the Kame project looks like a powerful endorsement for juice. In a study of 1,836 Japanese Americans in King County, Washington, who were followed for nine years. Those participants who drank juice once or twice per week had a hazard ratio of developing probable Alzheimer disease of 0.26. Those who did not report juice consumption had a hazard ratio of 0.84.

But a hazard ratio isn’t a measure of relative risk. Relative risk is the probability of an event occurring in an exposed group (juice drinkers) compared with an unexposed group (those who did not drink juice twice a week). For example, smokers have a relative risk of 20 of developing lung cancer: their risk twenty times that of nonsmokers.

Hazard ratios express the rate of an event occurring in one population (juice drinkers) versus a control population (non juice drinkers.) A test subject in a group with the higher hazard ratio has greater odds of reaching a specific endpoint first. In other words, the juice drinkers in the study had lower odds of developing Alzheimer Disease before those in the non-juice drinking group. A hazard ratio does not explain the extent of treatment benefit, so the dose of juice was not explained.

Furthermore, the Kame study only controlled for tobacco and alcohol use and a particular genotype found in Alzheimer Disease (ApoE). It did not control for significant predictors of dementia like family history or head trauma.

As an epidemiologist, one looks for certain key elements in research, such as a dose-response relationship and biologic plausibility. Mercola and the Kame study do not offer either of these core components of robust research.

Mercola’s claim that juice prevents Alzheimer Disease is not supported by the Kame study. The only possible claim is that there is evidence in one trial that drinking juice twice per week might forestall Alzheimer Disease in a specific population.

 

Joseph Mercola, the Questionable Advocate for Juicing

Perhaps Mercola is not the best advocate for juicing. Mercola was censured by the US Food and Drug Administration (FDA) in 2005 for making illegal claims about supplements. He then received a warning one year later, and the FDA warned him again in 2011. One would think that a single action form the FDA would lead one to back off, but Mercola’s supplement and book sales must be so lucrative that he is willing to look beyond censure.

Although his license remains active without sanctions, Mercola reputedly had a three-year battle with the Illinois Department of Financial and Professional Regulation, and he stopped practicing in 2012. In addition to his juice claims, Mercola opposes fluoridation, screening mammography, dental amalgams (fillings), and vitamin K administration to newborns. Although there are some debates about the appropriate ages and intervals for mammograms, these are not controversial subjects in public health.

Mercola’s allies are similarly problematic. His endorsements from a Dr. Andrew Saul are worrisome. Saul claims to have a “nontraditional PhD in ethology.” His other colleague, a Dr. Abram Hoffer, supported the use of niacin to treat schizophrenia. The research was later discredited because the diagnostic test to establish a diagnosis of schizophrenia was called into question.

Perhaps the juice industry would benefit from solid research rather than “expert” opinion from supplement profiteers like Joseph Mercola.

 

Is Juice Healthy?

Juice is not exactly a low-calorie, low-carbohydrate choice compared with soft drinks.

250 mL Serving Size

Carbohydrates kCal
Apple juice 28.97 110
Coca-Cola 35.18 105
Orange Juice 27.20 118
Pineapple Juice 32.18 140

 

One could argue that juice contains vitamins, which are not found in soft drinks. But a serving of apple juice, for example, contains only four percent of the recommended daily allowance (RDA) of vitamin C. It really is just sugar and water. It is true that other juices fair better in terms of vitamin C content, but vitamin C is found in a wide range of other foods contained in the typical Western diet.

Fresh-squeezed juice, however delicious, is also troublesome from a food safety standpoint. In fact, one of the first cases I was assigned as an epidemiology student was an outbreak of salmonella at a Florida resort. The CDC referred to outbreak location as “Theme Park A” (no prizes for guessing: it is in Orlando and has a mouse mascot.) The acid in juice was deemed to be protective, but the sweeter nature of fresh-squeezed orange juice meant that it was less acidic and thus less likely to contain salmonella. Outbreaks of Escherichia coli 0157:H7 and cryptosporidia have struck apple juice and apple cider. So much for “detoxification.”

 

Make no mistake, juice is delicious. I love fresh-squeezed juice from Tamara, I take the risk and buy unpasteurized orange juice—enjoying a small glass with my coffee in the morning. But it is not a detoxifying superfood. It is a nice dose of sugar when I wake up. But I am under no illusions. I could just as easily have Coca-Cola, it is not going to lead to weight loss, and it certainly is not going to detoxify anything.

 

 

References

Barrett S. FDA Orders Dr. Joseph Mercola to Stop Illegal Claims . Quackwatch. 6 September 2015. http://www.quackwatch.org/11Ind/mercola.html Retrieved 20 December 2015.

Cassell DK, Gleaves DH, The Encyclopeida of Obesity and Eating Disorders: Third Edition. New York: Facts on File. 2006.

Cook KA, Dobbs TE, Hlady W, et al. Outbreak of Salmonella Serotype Hartford Infections Associated With Unpasteurized Orange Juice. JAMA. 1998;280(17):1504-1509. doi:10.1001/jama.280.17.1504.

Dai Q, Borenstein AR, Wu Y, Jackson JC, Larson EB. Fruit and Vegetable Juices and Alzheimer’s Disease: The Kame Project. The American journal of medicine. 2006;119(9):751-759.

Fatsecret.com https://www.fatsecret.com/ Retrieved 23 December 2015.

Jamba Juice. http://www.jambajuice.com/menu-and-nutrition/menu/boosts/boosts. Retrieved 20 December 2015

Kelm H. A Reply To The American Psychiatric Association Task Force Report on Megavitamin and Orthomolecular Therapy in Psychiatry: The HOD Test” Orthomolecular Psychiatry 1978: 258–262.

MacVean M. Juicing Trend Still Going Strong in 2015. The Los Angeles Times. 29 January 2015. http://www.latimes.com/health/la-he-juice-20150131-story.html. Retrieved 19 December 2015.

Mercola J. Health Benefits of Juicing. http://articles.mercola.com/sites/articles/archive/2015/04/11/health-benefits-juicing.aspx

Mercola J. Juicing : How Healthy is It?http://articles.mercola.com/sites/articles/archive/2014/04/19/juicing-benefits.aspx Retrieved 20 December 2015.

Mercola, Joseph. Malpractice settlement 23 December 204, $387,925. https://www.idfpr.com/Applications/ProfessionProfile/ProfileDetails.aspx Retrieved 21 December 2015.

Mohammadi D. You can’t detox your body. It’s a myth. So how do you get healthy? The Guardian. 5 December 2014. http://www.theguardian.com/lifeandstyle/2014/dec/05/detox-myth-health-diet-science-ignorance. Retrieved 20 December 2015.

Omenn GS. Chemoprevention of lung cancers: lessons from CARET, the beta-carotene and retinol efficacy trial, and prospects for the future. 2007. European Journal of Cancer Prevention. 16:184-191.

Saul, A. http://www.andrewsaul.com/bio/. Retrieved 21 December 2015.

Tropicana. http://www.tropicana.com/#/trop_healthbenefits/hbMain.swf Retrieved 20 December 2015.

Watson R & Hodgekiss A. Fruit juice should not count in our five-a-day because some versions ‘contain as much sugar as fizzy drinks. Daily Mail. 10 February 2014
http://www.dailymail.co.uk/health/article-2555758/Fruit-juice-NOT-count-five-day-versions-contain-sugar-fizzy-drinks.html#ixzz3vCiNcpyB. Retrieved 23 December 2015

Wilson J. Juicing Pros and Cons. CNN 11 April 2014. http://www.cnn.com/2014/04/11/health/juicing-pros-cons/ Retrieved 20 December 2015.

World Health Organization. Top Ten Causes of Death http://www.who.int/mediacentre/factsheets/fs310/en/ Retrieved 20 December 2015

 

All images public domain

©2015

 

 

Faces of the Enemy: What Makes a Bond Villain

Matt Freeman

 

Alex Boucher and James Bachelor are hosts of Bond and Beyond. They have explored the Bond film franchise from a multitude of perspectives: music, design, acting, cinematography, and direction. As they have come closer to completing an analysis of each individual film, Alex and James have moved “beyond” to look at the films in a broader context. It is an unprecedented level of depth for establish Bond fans and new followers alike.

 

The films comprising the James Bond franchise are estimated to have generated £3.9 million for every minute filmed.  Beginning in 1962, the Bond collection of films has enjoyed some of the widest viewership and largest profits in the movie industry. Some have suggested that half of the world has seen a James Bond movie.

The recurrent Bond themes are not subtle. The films present consistent messages about masculinity, good, and evil.

The pervasive characteristics of the Bond villains teach viewers who to fear and who are allies may be.

“Why have you disobeyed my strictest rule and come in daylight?” asks the disembodied voice of Dr. Julius No. Quivering, Professor Dent says, “I came to warn you.”

“Warn me?” questions Dr. No.

His voice is clipped, robotic, and vaguely foreign. Professor Dent’s fear cues the viewer to be particularly frightened by the disembodied voice of the enemy.

Dr. No, the villain in the first of the “classic” Bond films, set the archetype for the majority of future villains. The villains typically display the following three properties:

  1. Foreign: particularly predominantly German or Russian
  2. Disabled or otherwise exceptional of figure
  3. Sexually ambiguous or homosexual

These tropes were not innovative. Hitchcock’s antagonists often met these criteria. Alex Sebastian in Notorious is German with a slightly fey demeanor, and a deep attachment to his mother. Phillip Vandamm and Leonard in North by Northwest as well as Brandon Shaw and David Kentley in Rope are gay couples and principal antagonists. Edward and Lucy Drayton in The Man Who Knew Too Much are presumably British in origin, but they have devoted their allegiance to an unnamed foreign power.

NNWPhillip and Leonard confront Eve and Roger in North by Northwest

Hitchcock’s films are certainly more studied, and are analyzed in the context of cinema as art. The Hitchcock films are also more varied in their themes and settings. The 007 collection of films are more homogeneous in themes and plot-lines. They are thus viewed more as an entertainment than art. Television stations count upon Bond films for wide viewership and advertising dollars. Serial television presentations—“Bond Weeks”—are common in many countries.

I have limited discussion to the first 14 Bond films, which are arguably distinct from the rest of the franchise. These films include those with James Bond portrayed by Sean Connery, George Lazenby, and Roger Moore.

 

The Foreign Enemy

Ian Fleming deliberately wrote Bond enemies to be foreign when he wrote the James Bond novels. During the 1950s and 60s, British colonies were seeking independence from colonial rule. Fleming’s novels would provide a reassurance that, “liberation of our colonies may have gone too fast… we still climb Everest and beat plenty of the world at plenty of sports and win plenty of Nobel prizes.”

Connery

In the cases of Donald “Red” Grant (From Russia with Love) and Pussy Galore (Goldfinger) the enemies are British but with questionable loyalty, and thus even more dangerous than an ostensible outsider.

The most significant example of foreignness of the enemy is perhaps Diamonds are Forever. Ernst Stavro Blofeld conceals his regular voice with a form of dialect-altering machine, which gives him a Texan accent. Although actor Charles Gray does not use a foreign accent as the “real” Blofeld, his name is certainly neither British nor American. The implicit message is: the enemy is foreign even if he does not sound like it.

The particular ethnicities of the villains reflect 1950s post-war sensibilities. The greatest number of classic Bond enemies are of German extraction. Even if the principal villain of the film is not German, there are German henchmen and hench-women. For example, in For Your Eyes Only, the primary villain is Greek: Aristotle Kristatos. But two of Kristatos’ co-conspirators are from the German Democratic Republic (Erich Kriegler and Jacoba Brink).

There are two exceptions in the first 14 films: Live and Let Die, in which Dr. Kananga as his coworkers are from the French Caribbean. This was followed by The Man with the Golden Gun, in which the enemy, Mr. Scaramanga, is presumably Macanese.

Bond himself makes only a few attempts to misrepresent himself as foreign or alien. In You Only Live Twice he “becomes” Japanese with cosmetic changes, but his voice is still that of 007. He pretends to have poor English grammar posing as a Dutchman in Diamonds are Forever, but his appearance, pronunciation, and dialect are still very much James Bond. His other alisases, such as Mr. Fisher, Roger Sterling, St. John Smythe all speak without a foreign accent.

Bond is always British, even when in disguise.

The Disfigured Enemy

Disfigurement and disability can suggest that concealment: a prosthetic limb can imply artifice: a failed attempt to blend in. The Bond villains range from limb prostheses to nervous and mental disabilities obesity. Dr. No again set the prototype. In the novel, Julius No has lost his hands in a radiation accident. In the film, his gloved hands tell the story of his disability without dialogue. Standing next to a portrait of Napoleon II, the film implies that Dr. No. is struggling to compensate for physical inferiority.

Dr_NoBond and Honey arrive at dinner in Dr. No’s quarters

Ernst Blofeld in You Only Live Twice is ostensibly deformed by an eye condition combined with his diminutive figure. The tacit message: no matter how sinister and calculated he may be, he will always be physically smaller than James Bond, and his eye will forever be deformed.

In perhaps the most absurd form, Ernst Blofeld masquerades as Count Balthazar de Bleauchamp in On Her Majesty’s Secret Service. He claims to be a descendent of royalty, characterized by the absence of earlobes. Blofeld has seemingly normal ear anatomy in the film, but he calls attention to it as both a deformity and a symbol of his heritage.

Similarly, Francisco Scaramanga in The Man With the Golden Gun, has a more curious than frightening deformity. He has polythelia (a third nipple). Although a common anatomic finding, the film uses the condition to represent the strange, foreign, or grotesque. 007 even attempts to disguise himself as Scaramanga with a cosmetic third nipple. After his attempt to disguise himself as Scaramanga, he rips off the prosthetic nipple, as if it were far to unsightly for his own body.

Professor Karl Stromberg in The Spy Who Loved Me has a subtler disability. The backstory is never presented. His assistant, Naomi, cautions Bond and Major Anya Amasova, “Professor Stromberg prefers not to shake hands.” This could imply the germ phobia of an obsessive-compulsive disorder or a neuromuscular condition that prevents a handshake. Stromberg is able to use his hands, and they are not prostheses. The viewers see him operate the control panels that lead to the death of his assistant, and to the explosion that kills Dr. Bechmann and Professor Markovitz.

General Orlov in Octopussy does not have named disability, but his movements have a spasticity that is most commonly seen in Parkinson Disease. It can also be a feature of hypoparathyroidism, Huntington disease, amyotrophic lateral sclerosis (ALS) and multiple sclerosis.

Auric Goldfinger and Hugo Drax (Moonraker) are not necessarily disabled with a specific illness, but they appear to be in poor health: obese, with slower movement.

Their disability is relative to Bond’s athletic physique and quick movements.

The most complex of the disfigurements is not displayed on screen. Max Zorin (A View to a Kill) was a product of a Nazi experiment to inject pregnant women with large amounts of steroids to create intelligent by psychopathic children.

Zorin
Max Zorin

Secondary antagonists also have their share of physical disfigurement and disability:

  • Oddjob (Goldfinger) and Sandor (The Spy Who Loved Me) are mute.
  • Tee Hee (Live and Let Die) has a hook prosthesis in lieu of a hand.
  • Nick Nack (The Man with the Golden Gun) is a dwarf.
  • It is unclear if Jaws (The Spy Who Loved Me and Moonraker) has metal teeth due to a disability or simply as a weapon. In either case, he is visually disfigured.
  • Scarpine (A View to a Kill) has a large scar on his face.
Oddjob
Oddjob

 

The Enemy as Homosexual or Asexual

The sexual orientation of Bond  enemies can range from unequivocally lesbian (Rosa Klebb,) to “camp” homosexual (Ernst Blofeld, Mr. Wint, and Mr. Kidd in Diamonds are Forever). Only three of the primary villains in the first 14 films even suggest heterosexual interest: Emilio Largo (Thunderball) presumably has an abusive sexual relationship with Domino, and Francisco Scaramanga (The Man with the Golden Gun) may have some sort of relationship with Andrea Anders, but this is vague and off screen. The relationship between Max Zorin and May Day (A View to a Kill) is physical, but it is unclear if it is sexual or romantic.

DiamondsMr. Wint and Mr. Kidd

The association between homosexuality and villains is most notable in the cases of Pussy Galore (Goldfinger) and Octopussy. In the novel of Goldfinger, Bond looks forward to Pussy Galore as a conquest: “the sexual challenge all beautiful lesbians have for men.” The film, produced in the era of tighter censorship, never defines Pussy as lesbian. Although she says she is “immune to [his] charms,” Bond rapes her, and the two end up alone in the tropics.

Pussy Galore is initially allied with the enemy, Goldfinger, but her allegiances change. As she becomes a part of the protagonist’s world, she becomes heterosexual.

Octopussy follows the same paradigm. We first meet Octopussy at her all-female island. Guards aside, the only man on the island is Prince Kamal Khan, who seems to take no interest in the population of attractive women around him. “Girls,” he scoffs, “they will keep the men occupied.” Initially disinterested, Octopussy falls for Bond, and embraces heterosexuality. Simultaneously, she breaks ties with Khan, thereby switching sides both in terms of her loyalty and her sexuality.

Hillary_Bray
James and Tracy. He is disguised as Sir Hillary Bray

Bond himself uses homosexuality as a guise. Amid foreign territory in On Her Majesty’s Secret Service, Bond presents himself as Sir Hillary Bray Baronet, an effeminate and bookish historian. One of the guests at the Piz Gloria “clinic” comments, “But I think you do not like girls, Sir Hillary.”

Unlike the flexible sexuality of Octopussy and Pussy Galore, Bond’s attempt to cloak himself in homosexuality fails quickly. Unable to suppress his heterosexual urges, Bond sneaks into rooms at the clinic in order to have sex with the young women.

The most common theme, however, is asexuality. James Bond’s appetite for women and sex is overall insatiable. His enemies, however, seem indifferent. Clothed in unisex tunics, they are often oblivious to attractive women in their presence:

  • No is never seen with Miss Taro, Sister Lily, or Sister Rose but Bond flirts with them. Dr. No is similarly unimpressed by Honey Ryder’s femininity and skimpy clothes.
  • Goldfinger certainly has access to beautiful women: the Masterson sisters, Pussy Galore, Mei-Lei, but he barely glances at them.
  • In You Only Live Twice the sexually provocative Helga Brandt speaks of her sexuality only in the context of henchman Mr. Osato, not with Ernst Blofeld.
  • In On Her Majesty’s Secret Service, Blofeld pays little attention to the young women at his allergy clinic. Irma Bundt is arguably a bit more interested in them, but she too is asexual.
  • Karl Stromberg in The Spy Who Loved Me ignores his beautiful assistant, Naomi. He has no empathy for his unnamed secretary, who he sends to sharks to be eaten. Similarly, he pays much more attention to Bond than to his Soviet paramour, Anya Amasova.
  • Hugo Drax (Moonraker) arranges for tea to be served to young women at his palace, and he employs Dr. Holly Goodhead. But Drax’s eyes never wander; he is never seen to show any attraction to the women in his presence.
Sister_rose
Bond flirts casually with Sister Rose, Sister Lilly, and Honey

The notable exceptions are in Thunderball and possibly Live and Let Die. In the former, one can assume that Emilio Largo has a relationship with Domino, albeit non-consenual. In Live and Let Die, is it unclear if Dr. Kananga has sexual attraction to Solitaire.

In only one instance is an ally presented as obviously gay. Dikko Henderson is an MI6 operative in Tokyo. He speaks of the doorman at the Soviet Embassy, who provides him with vodka, “among certain other things.” Moreover, Henderson has a wooden leg, contradicting the pattern of disability as enemy. Henderson is murdered seconds later.

 

Psychological Theories and the Bond Villains

One can apply multiple theoretical orientations to the psychology of Bond villains. This is in terms of both the villain and the viewer.

In perhaps the simplest form, Freudians would view Bond villains as living by the “pleasure principle.” Unburdened by ethics or a superego, the villains eat, drink, and kill on a whim. The Bond villains fulfill fantasies of murdering one’s enemies without consequence. Living in lavish quarters the Bond villains can extinguish their enemies with the touch of a button. They indulge in elaborate banquets. Their uninhibited access to power and luxury appeal to a deviant side within us.

Abraham Maslow’s hierarchy of needs suggests that Bond enemies have stunted development. The villains are solitary, lacking love, companionship, or even sex. Never surpassing the “love and belonging” ladder in Maslow’s hierarchy, the villains can never reach the human needs of self esteem and self actualization.

Followers of Carl Jung explore the notion of “healthy confrontation.” There is a psychological need for individuals to examine their “shadow selves.” Insight into hidden natures is a healthy form of development. The healthy unleashing of a shadow self is comparable to Bruce Wayne unleashing his inner Batman. The Bond villains never reach a level of self actualization. They exist only with malevolent traits, failing to integrate good and evil.

In the context of sexuality, Vito Russo described the appeal of stock “sissy” characters. This can be extrapolated to Bond villains who are either clearly homosexual or ambiguously so.

These characters give men a reassurance of their masculinity and women of their femininity by occupying the space between genders.

The viewer can then ally himself or herself with Bond rather than a villain. Recognizing one’s own scruples and self-control, the viewer can argue that he or she is more sophisticated than simple wish fulfillment. The viewer is superior to the Bond villain because he or she presumably has more meaningful social and romantic connections. He or she is more self-aware than a villain, recognizing a multi-dimensional personality. And he is assuredly masculine; she assuredly feminine because they are unlike the murky sexuality of the villains.

 

The Bond films can reinforce a xenophobia and homophobia, but the films themselves should not be impugned. They represent prevailing attitudes from their era of production. Astute viewers recognize that the foreign, disabled, and sexually ambiguous enemy was a means to assure viewers, “at least I am not like that.”

Flying_SchoolSelf esteem is not much of a struggle for 007.

The films have evolved to some extenDrN02t. Bond’s superior was a woman for many films; his personal assistant is black. In the most recent film, Skyfall, the antagonist, Silva, implies that Bond himself has had same-sex encounters. Disability and disfigurement remain unchanged. Silva makes a nauseating display of his deformed teeth. Le Chiffre (Casino Royale) suffers from uncontrolled asthma.

The Bond phenomenon will always be a source of impressive entertainment and increasingly spectacular cinematography. As the films have changed to suit modern audiences, the opportunity to explore Bond movies as social commentary expands. With astoundingly wide viewership around the world, Bond films serve as a mirror of how we view ourselves in the constructs of nationality, illness, and sexuality.

 

References

Dubrow J & Gidney C. The Good, the Bad, and the Foreign: The Use of Dialect in Childrens’  Animated Television. The Annals of the American Academy of Political and Social Science. 1998: 557.

Fattal I. Why Do Cartoon Villains Speak in Foreign Accents? The Atlantic. 4 January 2018

Frayling C. If Bond villains reflect the anxieties of their era, what can learn from today’s baddies? The New Statesman. 6 August 2015

Gilbey R. How James Bond villains reflect the fears and paranoia of the era. The Guardian 1 August 2012.

Lagley T. Why do supervillains fascinate us? A psychological perspective. Wired. 27 July 2012.

Martinez J. What makes a great James Bond villain? Newsweek. 6 November 2015

007 Movies: James Bond’s Killer Stats. The Fashionisto. 1 November 2015.

©2018
All images labeled for non-commercial re-use

Meg Ryan is Making Me Sleepless

Matt Freeman

Annie Reed (Meg Ryan) is the romance-enthused journalist in Sleepless in Seattle. Driving between Baltimore and Washington, Annie becomes infatuated with Sam (Tom Hanks), a lonely widower bearing his soul on a radio show. With daring speed, Annie abandons her boyfriend, Walter (Bill Pullman), and becomes entangled in a slightly saccharine romance with Sam.

In the Christmastime setting of the film, Annie seems somehow reasoned in her actions. Annie (and the audience) have a distaste for Walter. Walter is a downer. He seems perhaps detached, less intense than Sam. But his fatal flaw is a humidifier at his bedside.

Humidifier
Walter would have been fine—even marriage material—but not with that humidifier and those allergies. Thank goodness Annie stalked Sam and dodged that Benadryl-laced bullet! A humidifier? Walter might as well have been in Boko Haram. Good riddance!

Quietly judging Walter for decades, my life took a turn of events in which Walter’s humidifier took center stage.

Ever since graduate school, I was told that I snore. Some neighbors in Stockholm once mentioned that they could hear me from next door. A roommate on a school ski trip was hopelessly annoyed. I figured that this was a function of fatigue and alcohol, both of which are cornerstones of graduate studies.

In paramours that involved frequent overnight stays, I had some snoring complaints, but these were usually joking or just for eye rolling. There were no threats of Annie Reed-style departures.

On two occasions, I saw sleep specialists to ensure that I did not have some sort of correctable deformity. Both offered reassurance.  I did not smoke, was not a heavy drinker, unexceptional of figure, and did not have some sort of problem with nasal or oral anatomy. If I snored, so what?  My dog snores.

I experimented with every possible remedy: an “oral appliance” that essentially inflicted enough pain so that one never falls asleep. I tried costly anti-snore pills of dubious origin. There were nasal sprays, nasal strips, nostril inserts. They all made their way to the rubbish bin quickly.

SnoreStop

For reasons I cannot entirely explain, the symptoms worsened over a short span of time: less than one year. I had moved countries, gained a few pounds, deeply stressed, and was working absurdly long hours. I noticed that I would somehow hear myself snore and awake myself at night. My fatigue progressed, and I was nodding off while driving. I drew the line when I almost wrecked my car while a friend was in the passenger’s seat. I’d rather not be a homicidal driver.

Again, I sought medical advice. I was told the obvious: I worked too hard; and thus when I slept, it was both insufficient and of poor quality.

I argued again of my concern for sleep apnea. I knew from my own practice that it is underdiagnosed, undertreated, and deeply dangerous. I had probably ordered 100 sleep studies in the past year or two. “A-ha!” I would think to myself, “A wise diagnosis. You have helped the patient and protected the public! Bravo!”

Little did I know that I was creating Walters. (In the film, it is most likely a humidifier, but a 2017 Walter would be sleep apnea material.)

The sleep study itself was conducted at home. It was comparatively benign: a small nasal cannula that fell out constantly, pulse oximeter on my finger that slid off every few minutes, and an awkward chest strap. Since I usually sleep on my stomach or side, it was oddly painful, but I endured.

HST

A sleep study in the “comfort” of your own home. What could possibly get in the way of good night’s rest?

The results came soon, and I was told I had severe sleep apnea. I was mortified. But I had the idea that if I treated it, life would be so much better. The stress of work would dissipate, I would be overcome with renewed energy, libido, and my world would be like some sort of television ad for detergent: everything refreshed and renewed.

The ads for sleep apnea equipment were compelling. Erstwhile continuous positive airway pressure (CPAP) had given way to the gentler “autopap”. The machines were heated, humidified, and easily transported. It would be like a user-friendly iPod that would ensure a brilliant night of rest, and greater joy during waking hours.

DreamWear

The language in the ads referred to “dreams,” “pillows,” and “rest.” Through the genius of modern science, I would glide into bed, warm and humidified air granting me peace, resilience, and vigor.

The ads never mention Walter.

The “Dream Machine” was far larger than I had expected. Although it looked innocuous, that changed as soon as one attached the tubing. The cheery saleswoman had assured me that this machine would be effortless and unobtrusive. Using a nasal mask, it would be the least cumbersome. Moreover, it would “ramp up,” leading to increased pressure over time, adapting to my own tolerance. I fell for it.

I brought all the equipment home, and I made room for it at my bedside.

The machine would also report my adherence to my phone, so that I could see my “grade” for the previous night. If I did not feel judged enough for having the machine, I could feel judged by the machine itself.

N20

The minute I put on the mask, I thought of an oral surgeon. Perhaps around age seven or eight, a dentist told my older sister and me that we would both need to have six teeth removed simultaneously. This was somehow a prerequisite for orthodontia, which is a painful experience to share some other time.  (I am sure that Walter had braces well into is 30s. He probably still has them.)

The tooth extraction was not painful, but it was terrifying. The oral surgeon had a strange, alien demeanor. He was accompanied by a disinterested assistant with flaming red hair. He put a nasal mask on me that fed oxygen. Without warning, he pressed his whole hand over my mouth and jaw, then switching the line to oxygen mixed with nitrous oxide. I wanted to fight back, but I was powerless.

I had nightmares for years about that experience; and I still think about it now. I suppose gaseous induction of anesthesia spares the drama of putting IV lines into children, but there must be a better way to than to hold my mouth and jaw shut until I was rendered unconscious.

I told myself that the lovely, quiet, “Dream Machine” contained nothing but air and water; I would not be held restrained against my will. Soon I would just see the stars twinkle and the Man on the Moon would grin in approval.

The “Dream Machine” was at its lowest setting. It smelled like ozone (the machines are cleaned through ozonolysis.) It jammed air into me with jarring force. I adjusted every setting to reduce it to “gentle breeze” rather than its default, “tornado outbreak.”

CPAP

I did eventually fall asleep, intermittently taking the mask on and off.

Sensing distress, my dog jumped on to the bed, licking my hands. If he could speak, I’m sure he would have said, “Master, this is a bad idea.”

On about the fourth night, I slept only 90 minutes.

The next morning, I found myself lost in mid-sentence, a patient asked me if I had narcolepsy. I fell asleep at my desk, waking up to a screen full of commas.

Over the course of the first week, I had hit my head multiple times on the shower door, the tap, and almost yanked an entire towel rod off the wall. I’d woken up on the bathroom floor and on the couch in my living room.

Every morning, I would fall asleep and hit my head on a water glass or cup of coffee. I would wake up when the drink spilled. Each morning meant wiping off the spilled liquids and cleaning the carpet.

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Poor Walter.

Not only did he lose Meg Ryan, but he would no doubt be stuck with a “Dream Machine,” shoving air down his throat with breakneck pressure.

I asked a friend, “Who would wear one of these?”

“People who want to live,” he suggested. Point taken.

Again, thinking of Walter, I pointed out that nobody famous or attractive would be relegated to a “Dream Machine.”

“Ryan Gosling, Ryan Reynolds, and Ryan Phillipe do not have CPAP machines.” I quipped. “Zoe Saldana: definitely not a CPAP owner.” “Do you think Emma Stone goes to bed at night with one of these? Emma Watson?”

“Prince Harry does not have a CPAP machine.”

“You don’t know that;” my friend replied.

“Can we call Buckingham Palace and ask? What about Kate Middleton?”

Instead of pestering Buckingham Palace, I turned to Google. “Celebrities CPAP,” I entered.

The Ryans and the Emmas were not on the list. If Nicole Kidman wore a CPAP, she was keeping it under wraps. There was no mention of Idris Elba, Alexander Skarsgård, nor Amal Clooney.

The list featured Roseanne Barr, Rick Perry, and Rosie O’Donnell.

This was not uplifting news.

Right now, I am dreading even entering my bedroom. I have a beautiful, big bed with fluffy pillows, and layers of pressed white sheets. I now associate that room with the suffocating ozone smell of the “Dream Machine.”

Although I will consult with my own doctor, I am taking my dad’s advice: “Why don’t you lose a few pounds and not think about it so much?” He went on: “If the mental anguish of the machine is that bad; don’t use it.” And—of course—“hitting your head so frequently is probably not so good for your health.”

Indeed, I tried a night without the “Dream Machine.” I fell asleep in an instant, delving into all of the REM sleep I had been missing. I awoke calm, awake, and steady. And unlike my nights with the machine, I awoke without a headache.

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Annie Reed, I know you’re fictitious, but you should have been kinder to Walter. I am sure that he was unhappy with that machine at his bedside.

© 2017

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Suicide is Crazy: The Irrational World of Seeking the End

Matt Freeman

 

A few months ago, a young man came to see me. He was depressed. He had far exceeded typical depression. His speech and manner were slow. His eye contact was minimal. He seemed so sad as if tears were too much effort to shed.

This patient seemed to have a reasonably decent quality of life: otherwise good health, favorable finances, a stable job, and a loving family. He had a recent breakup with his girlfriend, but this was not excessively traumatic. On the surface, he did not seem to have reason to live in such pain.

He told me that he wanted to die.

He evaded questions about any specific plans. I worked with him and his counsellor frequently, and he is now doing well, living in another city.

 

I recognized his words and how he appeared. His hopelessness and emptiness were all too familiar. Some years ago, I came within a few minutes of taking my own life.

Just as it seemed crazy that this guy would die at an early age; it now seems just as crazy that I had walked in the same shoes.

 

Theories of Suicide

Psychologist Thomas Joiner described the suicidal individual as one who is overcome with isolation and a sense of burden upon others. Emile Durkheim characterized suicidal people as emotionally dysregulated: either removed from society or so altruistic that they fear burdening others.

According to Durkheim, a suicidal person could be either too broken as to ignore a moral compass, or conversely tightly bound to crippling perfectionism.

Aaron Beck wrote how those who succumb to suicide are “sensitized” to the notion of killing themselves by suicidal experiences, thereby making the final act somehow more accessible.

There are perhaps a dozen more theories, all trying to explain what leads a person to end his or her own life.

 

Theories of suicide may provide comfort to the bereaved, guidance for therapists, and a framework for suicide prevention. But the theories perhaps try to explain the inexplicable.

One of my favorite colleagues, a clinical psychologist, took a more straightforward approach. “Think of it in terms of problem solving. A person is suffering, so he or she seeks a list of possible solutions. Somehow suicide ends up on the list, even though it makes no sense to an outsider.”

I am writing about suicide as a release from emotional pain and mental illness, not the planned suicides of those with terminal diseases. These are controlled, programmed journeys to the end of life. It is an understandable escape from pain and indignity.

I write instead of suicide that makes no sense. Suicide is not necessarily an act of logic. The hopelessness and emptiness that surround the will to die are muddled, indistinct infections of the mind.

 

Where Burnout and Depression Meet

I knew what depression was. I had experienced its grip, but a commitment to suicidality was different. Although everyone experiences it differently, depression felt like a frustration and conflict with life. Suicidality felt that life was immaterial.

There is increasing attention to burnout among healthcare providers. Not enough attention, but at least a bit. I found myself working inconceivably long hours—sometimes out of necessity; sometimes to escape from an otherwise empty existence.

In the assessment of suicidal risk, the unfortunate term “trigger” is the first item on the list. It could be a loss of a loved one or friend, an illness, a divorce. In my case, it was the all-too-common threat of a dysfunctional and menacing workplace.

The abyss deepened as a recognized the venom of work. Concealed beneath the veneer of a “we’re all family here” façade, I was mired in politics and backstabbing that driven by a culture pervasive with hatred, secrets, and seemingly constant dismissals. Characteristic of a sick workplace, employees would disappear overnight.

It is a story told quite frequently in America: there have been front-page articles about Amazon, Microsoft, and—of course—Enron. I lived in constant fear of being berated and dismissed despite my popularity with my own supervisors, colleagues, and my patients.

Depleted of all energy, crushed with loneliness, and a biting work environment left my life feeling not just depressed but entirely unworthy. Although worthlessness is a symptom of depression, this was not just “I’m no good,” it was a total and all-encompassing feeling that life had no value. No medicine, no workbook, no cognitive exercise could extricate me.

 

Legend Versus Practicality

There is a glossed, almost benign nature to legendary suicides. One’s mind turns to Sylvia Plath’s oven or Socrates’ sprigs of hemlock.  These were undoubtedly violent—even disgusting deaths. But the gore is washed away. I thought of the The Aokigahara, Japan’s “Suicide Forest” or the Golden Gate Bridge. These seemed like misty outposts for a quiet exit rather than nightmarish sites of early death.

When my last stages of planning were underway, there was no poetry, no drama. Suicide was a remarkably practical endeavor. I ensured that my patients’ charts were suitable for someone else to take over, that my apartment was tidy, and I had made careful plans for my dog to be at a kennel. I even emptied my refrigerator as to ensure that the smell of spoiling milk would not disturb the neighbors.

The plan I had selected also made every effort to prevent me from being found. I did a couple of “dry runs” to make certain that I could get it right. I did not want anyone to stumble upon a decaying body, nor did I wish for any sort of funeral. I just wanted to disappear from this earth. Swiftly, quietly, in a cold, rainy night.

I also wanted to be certain that I did not end up in lace-less shoes playing musical chairs with meth addicts and schizophrenics on a locked psychiatric unit.

The questions I asked myself were not related to life or death. I wondered if I should leave my door unlocked, where to leave my car keys, and if I needed to take my wallet. In the loss of rational thinking that characterizes the most immediate of suicidal thoughts, “Should I do this?” was not on the checklist.

 

The Mask of Professional Identity

The deepest irony was that I spent much of my work dealing with suicidal patients. I taught classes on suicide assessment, I visited patients and families in crisis centers and psychiatric units.

Perhaps once a week, I found myself conferring with colleagues about the potential suicide risk of a patient. I even earned ironic praise for handling the suicide of a patient with grace and calm.

While talking with patients who expressed suicidal thoughts, I often found myself thinking, “Oh, you’re definitely not suicidal. I am suicidal.” Maybe it was my own escalating will to die that made it so easy for me to convince others that that they were not in such dire condition.

In a bit of macabre humor, I found myself taking suicide risk inventories. In my perfectionist, over-educated world, I wanted a grade. I never seemed to score that high. I was not physically ill, I did not fall in the right age ranges, I lacked a substance abuse problem, and my finances were not in jeopardy. I was failing the suicide tests.

 

The Note

Comedian Sam Grittner wrote about the strange task of writing a suicide note. He stumbled over font choices and he ran out of ink for his printer. I was fortunate enough to have a laser printer with adequate toner; and I was pretty set on using Palatino.

Although I wrote several drafts, they never seemed to say anything other than “I’m sorry.” I felt like including a few “fuck you’s.” It occurred to me that those I would mention were such sociopaths that they would be unlikely to be moved or even saddened by a suicide. I was not really interested in teaching anyone a lesson.

I never printed the note. I kept wondering where to put it, and if anyone would bother reading it. What purpose would it serve? I did not want anyone thinking, “Oh if only…” I did not want anyone thinking of me at all. I wanted my life erased.

One of the most frustrating lines is, “It was such a selfish act.” Suicide is a desperately-needed escape from a life too painful or meaningless to continue. Selfishness implies indulgence, diversion of resources to oneself. Suicide feels like the opposite of siphoning off the assets of others. It is one less mouth to feed, one less salary to pay. I even thought it would be a benefit to the healthcare system: one less patient availing himself of costly benefits.

 

An Unhealthy Dose of Guilt

It seems like human nature to seek comparisons. I was beyond the point of reflecting on my life, but I would sometimes get flashes of world news. “You could have ALS,” “You could be living amid genocide, war, appalling poverty… So many people have it worse than you do.”

This only adds to the damnation of suicide as “selfish”. The imminent will to end one’s life has nothing to do with Darfur or Donetsk. It is neither reassuring nor helpful to imagine squalor and pain elsewhere in the world.

“Count your blessings” has a pop psychology, Dr. Joyce Brothers superficiality. If one is truly committed to dying, “counting blessings” sounds like a childish diversion. Flip as it may sound, it would be the equivalent of saying, “I have an iPhone and I do not have cystic acne. Wow! This is fantastic! I should stay alive after all!”

It is also similar to saying, “It can’t be that bad.” In those last days and hours, there is no “bad” or “good”. It is only a matter of, finding an end. The pain is suppressed; one’s focus is just to make life disappear.

 

The Particular Burden of Professional Licensure

The most heartless and sinister aspect of being a healthcare provider struggling with suicide is that many state laws require investigation, oversight, and practice restrictions on doctors and nurses who “get caught” admitting to suicidal thoughts. In a misguided effort to “protect the public,” licensure boards crack down on those most in need of help, punishing anyone who reaches out at the last moment before leaving this world.

The boards tacitly endorse suicide: it is far easier to be dead than to have to suffer a public disclose one’s most painful, innermost thoughts repeatedly for the remainder of one’s career. Had I been hospitalized, the law would have required that the licensure board issue a press release, warning the public that I was mentally unwell. Any member of the public would be able to read the most intimate details. I would spend the rest of my career providing documents of my mental instability to insurance companies.

 

Reverse Course

I paused. I do not know why. I doubt I will ever know why.

To paraphrase Sam Grittner: “Pro Tip: always call your therapist before pulling the trigger.”

“Pro Tip: always call your therapist before pulling the trigger.”

I had a psychologist. A wise, warm, and clever professional. He was deeply caring with an unmatched sense of humor.  Trying avoid alarm, I did not call from a bridge, nor did I bother him in the middle of the night. I spent the remainder of that night agitated and foggy, and waited for his office open.

His response was what only the most confident and caring professionals would know to do: he gave me a huge hug, struggling to keep back his own tears.

There was no need for him to demand my shoelaces or submit me to the indignities of hospitalization. Without words, he was saying, “No. That’s not where this is going. You’re not doing this.”

He also knew to meet me in a place I knew well: the snarky gallows humor of medicine. We talked about how one particular attending psychiatrist was almost always on service at the nearby hospital. He was famous for being as arrogant as he was incompetent. If I somehow did not die from suicide, I could awake from a coma with that imbecile at my bedside.

I was deeply unwell, but made every effort to fake it. I got up went to work, and buried myself in routine.

I eventually moved on from the battles of my former job. Although it seems inconceivable, I just somehow did not feel like dying anymore.

 

Retrospect

Sufficient time has passed that I can think somewhat clearly about that dark 48 hours. The lesson I wish I could impart the most to others is that suicide makes no sense. One can read theory upon theory, but it is inherently irrational. I cannot explain why I did not kill myself.

Suicide assessments also try to impart some sort of method where there is no algorithm or equation. I did not score high enough on any of the “validated” suicide measures. There is thus a danger to suicide awareness campaigns and to clinicians who might turn to some sort of psychiatric inventory.

As I knew, the most lethally suicidal patients keep their mouths shut. Except at the very end; I said nothing. Although there is an art to working with more vocal patients, and their cries should not go unheard, it was a function of good luck that I happened to have a psychologist, and that he was both available and perceptive.

 

I think I am a better clinician because of my own experience. I obviously maintain boundaries and do not talk about myself. Like the patient in the introduction, I can at least feel a deep sense of empathy, and I try to take after the psychologist who looked after me.

Only the most monstrous of licensure boards would punish me for expressing my recollections here. I am no danger to myself–years have passed; and I was never a danger to others. I ended up avoiding the hospital, and thus would not meet the threshold for some sort of investigation.

 

Taking a cue from the “Make It OK” program and “The Hilarious World of Depression” series, I felt that sharing my own experience might just help someone else.

If that person is you, and you are reading this, do me a favor: wait a day. Call the person most likely to help you. I wish you a hug, honesty, and hope.

© 2017

for BB

Window Seat

 

Matt Freeman DNP, MPH

 

“Come with us.”

A soft-spoken airline agent gestured toward me.

“You don’t want to miss this.”

She saw me sitting alone, my eyes wandering out the window. Perhaps seven or eight airline employees gathered by massive floor-to-ceiling windows. “We always watch the sunset together,” she explained.

Several snapped photos with their phones.

The sun grew and glistened, the planes shimmering in neat rows. The endless crowds, congestion, and noise of LAX disappeared. It was just a few moments of collective appreciation of the planet. From there, flying took on a renewed, human quality. I took off that night, staring out at the stars from the window seat. It was a sensation of immeasurably profound calm.

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Fear and Fascination

The first time I was old enough to remember a big trip, I was sitting with my mother at Kennedy Airport. Only the nose of the 747 was visible from the window. It seemed like an improbable means to take flight, and I wondered if the “real” plane was hidden behind it. This was all some illusion.

Nobody had told me that the flight would take place at night. It seemed like an immensely bad idea. How would we find our way? How would we avoid bumping into another plane?

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Fatigue must have set in, and I nodded off.

I awoke next to my father, my ears popping. As I stared out of the window, I was transfixed. The wing had moving parts that extended and screeched. Wafts of mist shot across the wing surface. Fog and clouds spirited past the window. Beneath us lay something even more extraordinary: houses, electrical wires, grass, cars, road. We were landing in Milan, but I had no idea what to expect. I was dumbfounded that Italy had certain familiarities from home.

 

The Foreign and the Surreal

A couple of years later, I visited Heathrow Airport for the first time. The experience of flying took on a particularly enthralling mystique. Unlike anything I had seen before, digital signs heralded flights to Harare, Bratislava, Caracas, and Leningrad. There were planes from “forbidden” port of call: an Illyushin jet from Aeroflot taxied into a nearby gate.

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The next morning, we sat outside at the New Stanley Hotel in Nairobi. My family pointed out that the crew from British Airways was at the table next to us. It was like seeing a primary school teacher at the movies or supermarket. They were in casual clothes, having a beer in the African sunshine. It made little sense. In my boyhood imagination, these people lived on the 747. They would not wear anything other than deep blue uniforms adorned with ties and scarves styled after the Union Jack. Everything became even more magical and mysterious.

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My family was quick to indulge my fascination. My uncle would send me unused invitations to the business class lounge in Bucharest (aware that I was unlikely to have a Romanian holiday anytime soon.) My grandfather would take me to the airport to see the rare appearance of a DC-10 from JAT, an erstwhile Yugoslav airline. A neighbor who worked for El Al would tell me stories of his own travels on employee tickets. My grandmother shared stories of the furious immigration officer at Sheremetyevo Airport in Moscow.

 

The Joy Fades

Somehow the sparkle became routine, a hassle, bourgeois cocktail conversation. As I grew older, flying became about hassles, garnering points, and dodging high fares. As I grew larger and more discriminating, the size and pitch of the seats became bothersome, the food avoidable rather than interesting. I was once fascinated by the stamps and carbon copies by ticket agents, this gave way to endless crowds, and frustrating hassles.

As aviation terrorism resurged on US shores, I lost my interest with the unusual security procedures overseas, I developed particular fury with the nonsensical, humiliating, and seemingly endless absurdity of the Transportation Security Administration.

It took a moment that evening, standing and watching the sunset at LAX, to find the mystique and passion from the jumbo jets we board every day.

 

Re-Imagining Magnitude

The anxious clenched fists I felt as I stepped aboard a 747 as a little kid are best explained by the unthinkable scope of what it means to travel today. It is both mundane and astounding.

As an adult, I was sitting next to my father on flight from Newark to São Paulo. “How many dishes and plates do they go through?” He asked. I do not have an answer other than “a lot.”

 

Flight 85 is the most familiar to me. Every day, a Boeing 777-200 takes off from Gate C9 in Tel Aviv just after noon, arriving at Newark just after 5:00 pm, usually somewhere on the “C” concourse. Depending on the time of year, the flight takes about 11 and half hours.

Shortly after 9:00 am, the check-in counters open. Two hundred sixty-seven passengers are interviewed by the Israeli Airport Authority, their bags are weighed and tagged then screened. The passengers walk downward through a security checkpoint, immigration control, and then to a massive rotunda of 24-hour, seven-day duty free shops.

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About 90 minutes later, roughly 18 crew arrive, having spent the past 24 to 30 hours asleep, on the beach or touring Israel. There are typically two pilots, two “relief” pilots, at least four plain-clothes Federal Air Marshals, a purser or “Inflight Service Director,” about three Hebrew-speaking flight attendants, and five international flight attendants.

From the upper level of Ben Gurion Airport, the 777 is not particularly imposing. The airport is full of jumbo jets in the Middle Eastern sunlight. Unlike my fear of the 747 at JFK, the plane looks airworthy. From such a height, one can hardly perceive its 64 meter length (210 feet), and even greater wingspan. The engines themselves are seven meters (24 feet) in diameter. It seems implausible, but four of me could stand head-to-toe inside the engine.

As the ground crew starts preparations, the 777 will require about 220,000 pounds of fuel. This is measured in pounds in part for convenience. It is roughly the equivalent of 1,493,800 gallons. (5,654,648 liters). According to indexmundi.com, the cost of fuel would be $1.30 per pound or $286,000 for the flight. That does not account for the likely higher cost of Jet-A fuel in Israel. At $1071 per passenger just for fuel, suddenly the actual cost of the airfare does not seem quite so extortionate.

 

Roughly 45 to 60 minutes before pushback, a mix of crews from Quality Airport Services (QAS) and United Airlines start loading the 267 passengers: checking passports, asking few security questions mandated by the US government, and a glance at hand luggage to ensure that passengers comply with US laws about liquids. In an astounding 45 minutes, each wheelchair is stowed, each stroller is collapsed and tagged, each forbidden water bottle is discarded, and passengers negotiate with their neighbors to swap seats.

In the mid-day heat, the 777 uses the longest runway, a breathtaking 13,327 feet (4,026 meters).

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Despite endless web sites full of vitriol and ratings, the cabin on flight 85 offers the unimaginable. Passengers plug in to electrical outlets, log in to WiFi, flip through page after page of “on demand” movies and television shows.

In business class, a stainless steel cart passes through the aisle with the crew offering port and gourmet cheeses cut to the passenger’s taste. This is followed by another stainless steel cart with ice cream, warmed chocolate fudge, and liqueurs.

It is easy to forget that this is occurring at 560 miles per hour (901 kilometers per hour.) This is just about three quarters of the speed of sound.

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All of the Above Quadrupled

Perhaps the most remarkable fact is that a sister flight, number 91, will take off with another 267 passengers just under twelve hours later. Meanwhile, their counterparts (84 and 90) are flying from Newark back to Tel Aviv. Every day.

That means 1,068 passengers per day, every day, on just one route. In the roughest estimates, that is 2,136 hot meals, 5,000 paper napkins. If just half of the passengers participate in a frequent flyer program, more than three million miles will be earned.

Six days per week, the same route is replicated by El Al Israel Airlines, carrying at least an additional 279 passengers per direction.

That is one route on one day of the week.

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Finding Meaning

The hassles are seemingly endless: high fares, confusing web sites, strange fees, long lines, absurd security, delays, cancellations, diversions….

Look out the window.

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There is both joy and peace to be found amid the clouds. The views are unparalleled, particularly the sunsets.

There is a certain shock if one considers what constitutes a “routine” flight. It is so complex that one’s mind cannot begin to imagine 5,000 napkins.

Take a cue from the enamored staff at LAX: look out the window; snap a photo of the sunset.

 

©2016

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The Martha Mitchell Effect

Matt Freeman DNP, MPH

 

“It’s all happening. It’s happening now.”

I could smell a hint of whiskey or bourbon on my patient’s breath. His knee bounced up and down with anxiety; his eyes scanned the room. His speech  was forced hard to follow.

“She’s in the waiting room now. She could be calling them. I don’t know. She has been checking my phone. She eavesdrops. She knows people.

The patient had a long and complex story about how his criminal history prevented him from owning a business. Therefore, everything was held in his wife’s name, and she had been threatening to turn him in: to the police, the FBI, and ICE (Immigration and Customs Enforcement.)

His speech grew louder, he fumbled for words, occasionally losing himself mid-sentence. He stood up, paced, eventually sitting back down.

I assured that my patient was not in any immediate danger to himself or others, but I struggled to figure out how I could help him. I was happy to listen, but it seemed like he needed a divorce lawyer, maybe an immigration lawyer, perhaps treatment for substance abuse.

Naturally, I wondered about hyperbole. Was this man wanted by the FBI? Did he have a crippling criminal past? Was this a delusion?

 

One phrase stuck in my mind: “The Mouth from The South.”

In one of his interviews with David Frost, Richard Nixon remarked, “If it hadn’t been for Martha Mitchell, there’d have been no Watergate.”

Martha Beall Mitchell (1918-1976), was former schoolteacher from Pine Bluff, Arkansas. Her second husband was John Mitchell, former Attorney General under Nixon and subsequent head of the Committee to Re-Elect the President. The Mitchells ironically lived in the Watergate Building.

Julie_Nixon_Eisenhower_with_Martha_Mitchell_-_NARA_-_194649Martha Mitchell with Julie Nixon

 

Amid marital spats, prescription drug abuse, and alcoholism, Mrs. Mitchell called Washington journalists, often late at night. She spoke with Helen Thomas, Carl Bernstein, and Bob Woodward. Although the exact conversations were not recorded, Mitchell reportedly revealed her husband’s complicity in “dirty tricks” operations of the Nixon administration, particularly her husband’s Committee to Re-Elect the President (CREEP).

The phone calls famously came from her pink “princess phone.” Her Arkansas twang earned her the nickname, “The Mouth from The South.”

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Martha Mitchell became a celebrity, posing for television interviews and magazine covers such as People and New York.  She called for Nixon to resign, clarifying that the public was well aware of Nixon’s misdeeds. Her histrionic demeanor could have been inherent, a reaction to her husband’s efforts to silence her, or a function of alcoholism.

Mrs. Mitchell stated, “I’ve been persecuted more than anyone since Jesus Christ.” She made it clear that she wanted to be known as “Martha Mitchell, not Mrs. John Mitchell.” Her draw for attention was famously exemplified by her clothes. “What I wear,” Mitchell said, “nobody else would buy.”

Her motivations were not political. Although she clearly detested Nixon and CREEP, her “phone capers” erupted after learning that John Mitchell was reportedly dating one Mary Gore Dean. A snub to her ego and image pushed her to pick up the “princess phone.”

John Mitchell
John Mitchell subsequently served 19 months in prison

 

Motivations aside, Mitchell was billed by some as a hero. She spoke openly and publicly about a corrupt political administration. Coming across as a deranged and attention-seeking, Mitchell incited even greater interest in journalists, eventually leading to the downfall of the Nixon Presidency.

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The Martha Mitchell Effect

The Martha Mitchell effect in psychology and psychiatry refers to a failure of a clinician to verify potentially plausible claims of a seemingly delusional patient.

When I took abnormal psychology in 1994, I remember my professor, a clinical psychologist, citing an example. A patient of his claimed that he was being followed by the FBI. In attempt at reality testing, the psychologist and the patient sat together as the psychologist called the FBI. He inquired if his patient was under investigation. Indeed he was under surveillance.. The patient had written a threatening letter to Lyndon Johnson. The patient may have been paranoid, even struggling with a thought disorder, but he was still being followed by the FBI.

 

The patient who came to see me with stories of his wife, ICE, the FBI, was under the care of a psychologist. I relayed to her his concerns, and therefore left it up to her to pursue any investigation into the veracity of his claims.

Was his anxiety and paranoia due to an actual pursuit by the government, or was he delusional? I will never know.

 

The message is critical for any clinician: We all hear outrageous or bizarre claims of persecution, spying, and other threats. Even a patient under the influence of alcohol or drugs, even a psychotic patient, even a patient with a personality disorder can still be telling dangerous truths.

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References

John N. Mitchell Dies at 75; Major Figure in Watergate. The New York Times. 10 November 1988. http://www.nytimes.com/1988/11/10/obituaries/john-n-mitchell-dies-at-75-major-figure-in-watergate.html?pagewanted=all

Maher B. Anomalous experiences and delusional thinking: the logic of explanations. In Oltmanns and Maher B (Eds.) Deulsional Beliefs. Chichester: Wiley. 1988.

Martha Mitchell speaks out about Nixon, Watergate. 15 June 2012. BBC News. http://www.bbc.com/news/world-us-canada-18436516

McLendon W. Martha: The Life of Martha Mitchell. New York: Random House. 1979.

 

This blog entry was originally a lecture I gate at Pacific Lutheran University.

All images designated as public domain

© 2016

 

Warning Fatigue: Chatter and the Stress of Flying

Matt Freeman DNP, MPH

A trip through the terminal at Galeão/Antonio Carlos Jobim Airport in Rio de Janeiro is mundane, if not a bit grim… unless  you start listening. The steaming, sultry, deep voice of former newscaster Iris Lettieri is used to make announcements. Since 1977, Lettieri’s passionate voice has been used in Rio, and has since expanded to other airports in Brazil.

Every time I have flown in Brazil, I have been caught off guard by the sense of mystery and romance in her recorded voice.

If you have never been to Brazil, or have forgotten Lettieri’s voice, this NPR interview will introduce or reacquaint you. You will not be disappointed.

http://www.npr.org/templates/story/story.php?storyId=8976813

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Iris Lettieri is the exception.

Amid the many stresses of air travel, the overuse of announcements is grating, counterproductive, and exacerbates an already anxiety-producing experience.

Psychologists in the United Kingdom analyzed how repetitive announcements result in “warning fatigue.” Professor Judy Edworthy and Plymouth University described how listeners will “habituate” to a stimulus, and it will eventually be ignored.

There is a reasonably simple principle of neuroscience behind this: action potentials from a constant stimulus will decrease over time. As a physiology professor taught me as an undergraduate: this is why you do not smell your own perfume or cologne after a while.

 

Looped, Pre-Recorded Announcements

Edworthy’s argument is perhaps most evident in pre-recorded announcements. Journalists from The Telegraph identified twenty-seven public safety announcements during a 30-minute period at a London railway station. These included messages about using the handrails, using an elevator instead of an escalator if one has suitcases, and so on.

A spokeswoman for the railway company said that the messages were “for the safety of our passengers because we have had accidents.”

Lisa Lavia, a representative of the Noise Abatement Society, felt differently. “…the public really hate these announcements but feel powerless to do anything about them. But as the science is now showing, these nightmare messages are no longer just a nuisance–they don’t even work.”

 

Relevance

Perhaps the most baffling of looped, pre-recorded announcements advises passengers in US airports of restrictions on liquids and gels in hand luggage. This announcement is played repeatedly in the “sterile” area of the airport, after passengers have passed through a security checkpoint.

The irrelevance tacitly advises listeners, “These announcements do not apply to you. You have nothing to gain by listening.”

Anything significant, such as “the airport is now on fire,” would run the risk of being lost amid the frequent and meaningless other announcements.”

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Mass Confusion

During my first job after college, I attended a workshop on dealing with crowds and lines. One of the core lessons was: never, ever shout instructions at a large group. The typical responses are:

“What was that?”

“What did he say?

In a check-in hall at an airport, yelling “Anybody going to Chicago?” will likely create mass confusion. “Did he say Chicago? Was that our flight?” Then someone will yell from the back, “Chicago! That’s us!” The commotion escalates.

It is far easier to walk along side the crowd and ask, “Are you headed to Chicago?” Or, perhaps more productively, “Where are you headed today?” Although the illusion is that it might take longer, it is actually far more expeditious. One can identify the Chicago-bound passengers and direct them to the right place—calmly, personably. In the process, you might find that you have people in the wrong queue for the wrong airline and correct that problem too.

 

The Transportation Security Administration (TSA) has developed a reputation for so-called “barkers,” who shout instructions at groups of people waiting in line. The stressful experience of airport security is exacerbated by a barrage of repeated and blurred shouts.

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I recall one security checkpoint that was strictly for passengers transferring off of international flights. “Folks, you are about to enter a security checkpoint!” shouted the “barker.” It would be hard to imagine that anyone would be confused by the scene before them: x-ray machines, metal detectors, body scanners. After all, everyone in the queue had just gone through the same experience several hours prior. The remaining instructions were garbled, and certainly unhelpful to those who did not speak English.

I witnessed one TSA agent go against the trend. She smiled, stayed calm, and politely gestured to those who did not speak English to remove their coats and shoes. Unsurprisingly, she had the line moving far more quickly and without agitation. Furthermore, other passengers witnessed her polite demonstration, so the message propagated down the line. Without words and with a gentle smile, she silently had everyone on their way.

 

Shame and Admonishment

“We have a lot of material to cover today.” I remember far too many teachers and professors who would start off their classes with this warning. It was never helpful. After all, the professor wrote the syllabus, so it was his or her idea as to how much material would be covered in the designated instructional time. The initial pressure of “we have a lot to cover today,” just added stress without discernable benefit. What could students have done differently?

The same applies to “this is a very full flight.” This announcement precedes just about every commercial flight I have taken in or to the United States in the past few years. It is an introduction to the flight by admonishing and shaming passengers who have done nothing wrong; they just happen to be flying that day.

“We are expecting a very full flight” adds the same stress as, “We have a lot to cover today.” There is nothing I can do differently if the flight is full or empty: my hand luggage is the same size; my own height and weight have not changed. All I can expect is that I will feel perhaps more cramped than usual.

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Asking for the Impossible

Boarding is invariably the most stressful time for passengers and crew. There is the struggle to fit everyone’s hand luggage in a small space, find seats, relocate families who have been separated, and still get the plane out on time.

Instead of a self-regulating environment, passengers are bombarded with instructions to “step into [their] row” thereby leaving the aisle open for other passengers. Amid the chaos of fitting 150 people into a small space, the announcement just creates noise. If passengers self-regulate: moving and accommodating for one another, they need not pause to listen to an unnecessary announcement.

There is also the impossibility of “stepping into your row.” In a crowded single-aisle aircraft, one has to be patient as everyone else shuffles themselves and their belongings. Stepping into one’s row is not always an option. The announcement thus creates more disruption, and it asks passengers to accomplish the impossible.

 

Significance versus Fine Print

Gate agents and flight attendants read from announcements from smartphones, booklets, or from computer printouts. The longwinded nature of these announcements makes the fundamental error of mixing marketing, regulatory, and logistical information with the same cadence, length, and mixed in a single string of data. There is little sense of priority, and much of the information is superfluous.

 

Category Example Priority Can this be excluded?
Regulatory “Children under the age of 15 may not sit in an exit row.” Important
It is a federal law, but does it need to be announced?
Maybe. The gate agents and flight attendants could check this without an announcement.
Logistical “The flight time will be 3 hours, 25 minutes.” Intermediate relevance:
useful information for most passengers
Maybe
Logistical “We accept credit and debit cards with the Visa, MasterCard, and American Express logo.” Low relevance.
A passenger attempting to purchase something in cash might be informed of this only if such a situation arose. Why announce it?
Yes
Marketing “We are a founding member of the Star Alliance.” Minimal relevance
since passengers already purchased their tickets and boarded the flight.
Yes

 

Parsimony

Federal law (FAR Part § 121.317) requires that illumination of the “fasten seatbelt” sign have an accompanying oral instruction. This is not necessarily a bad idea, particularly for passengers who have vision impairments, or who might not speak English.

In reasonable situations, a crew member just says, “Seatbelts, please.” On a flight to Germany, the American captain just said, “Seatbelts, please. Bitte anschellen.” Four words. An unequivocal message is delivered in both languages, and there is compliance with US law.

Sadly, the four word announcements are rare. I often fly to and from Tel Aviv. The airline I often fly has a blaring, pre-recorded announcement. A woman’s voice at 10 out of 10 volume arouses one from sleep on an overnight flight saying, “Ladies and gentleman, the Captain has turned on the ‘fasten seatbelt’ sign. Please return to your seat and fasten your seatbelt.” This is followed by a Hebrew-speaking crewmember repeating the same message. Twenty words in English followed by 16 in Hebrew. The length of the announcement detracts from the core message: “seatbelt.”

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Redundant Information

In airplanes with video equipment, most airlines present safety information through a video presentation. These films are reviewed by the FAA, and the language has to be specific to meet regulatory requirements. As ridiculous as it seems, the law is clear that passengers must be shown how to buckle and unbuckle a seatbelt. (The idea is that airplane seatbelts operate differently than those in cars.)

Problems arise when crew restate information already in the film. This is particularly true of announcements regarding mobile phones and smoking. One could argue that this information needs to be reinforced to ensure adherence. “Nobody watches the film, so we have to announce it.” Another option is never presented: during the mandatory walk-throughs or “compliance checks,” the crew could just ask passengers individually to correct any reclined seats or obstructive luggage.

Instead of worrying about inattention to the video or announcements, why not just correct the safety problems as they occur?

 

Goal Setting

“Did you not hear the announcement?” is no longer a reasonable argument. There are so many announcements that one can easily become sidetracked. Furthermore, flying is tiring, rules vary, and some airlines and security checkpoints are stricter than others.

The TSA staff or airline crew would be wise to ask, “What is our goal?” Is the goal to have one’s announcements heeded, or is the goal to ensure that passengers are safe?

 

Moving Forward

The first question is, “How much of this information needs to be conveyed?” Aside from federally-mandated announcements, air carriers would be wise to explore passenger comprehension. During the roughly 60 minutes it takes from beginning boarding to reaching the runway, how many announcements are made? Of those announcements, what is the overall comprehension level?

Some of these issues are hard to measure. One cannot conduct a “placebo controlled” study to determine if repeated overhead announcements about leaving luggage unattended actually lead to greater attention to security. The decision to cease the announcements has to be based on principles of neuropsychology: repeated announcements will be ignored over time.

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Dialing it Down. How Can We Limit the Cacophony?

Since the “announcement culture” is ingrained in American air travel, it may take scientific analyses to argue for fewer announcements.
1. Measure Passenger Stress

Passenger stress can be assessed through psychological inventory or biological measures. Researchers could evaluate the magnitude of passenger stress as a function of the number of announcements (safety, logistical, and marketing.)

 

2. Measure Passenger Adherence

Some announcements are federally-mandated, but one could experiment with optional announcements.

  1. Conduct a trial in which one TSA checkpoint has an agent announces repeatedly that laptops must be removed from hand luggage; make no announcement in another checkpoint. See how many passengers remove their laptops between the two lines.
  2. Ask airline crews to measure the number of passengers who attempt to pay in cash as a function of a pre-flight announcement. Does the announcement actually affect adherence?

 

3. Measure Passenger Satisfaction

Airlines routinely collect extensive survey data. It would be easy to determine if passengers have greater satisfaction with their airport experience based on stressful announcements like, “This is a very full flight.” An air carrier could compare satisfaction surveys from flights where such language is prohibited to the status quo.
There are solutions to a calmer, quieter trip both on the ground and in the air. Although it would be pleasant to have the rich voice of Iris Lettieri all over the world, there is an obvious need to “dial down” the barrage of announcements.

 

 

References

Copping J. & Ljunggren H. Annoyed by public address messages? Now experts say they don’t even work. The Telegraph. 2 October 2011.

 

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