Liveblog: Health & Biology, HASTS 25th Anniversary Event

Liveblog November 10, 2013 10:50 pm

Screen shot 2013-11-12 at 7.20.00 AM

Co-written with Lucas Mueller, with additional help from  Julia Fleischhack and Amy Johnson; photos by Ashawari Chaudhuri and Amy Johnson. Wordle shows program interests between 1990-1994. 

The Health and Biology panel,  panel #2 at the 25th Anniversary Event,
introduced by Marie Burks and moderated by Lan Li.

Jennifer Mnookin (‘99): Knowledge, Culture and Forensic Science: What Fingerprint Experts – and Their Critics – Know

Anne Pollock (‘07): Health Disparities and American Citizenship Claims

Jenny Smith (‘06): From Soup Nuts to Curry-Flavored SPAM, a History of the Science and Politics Behind American Food Aid

Jessica Wang (‘95): The Telling Case: Rabies Narratives, Autopsy, and Medical Community in Nineteenth-Century New York City

 

Jennifer Mnookin (‘99): Knowledge, Culture and Forensic Science: What Fingerprint Experts – and Their Critics – Know

AC_Jennifer Mnookin

Since graduating, Mnookin has been examining forensic science in both the academic and policy realms, particularly how material evidence is differently approached and examined. In this talk, she will reflect on her most recent work on the structures of knowledge that operate within these two domains, as well as the challenges in (and real lack of) cross-talk between practitioners and academics on the subject of fingerprint identification in the criminal context. At stake in these two separate conversations – that, when they do overlap, are wracked with tension – is the role of human engagement versus expertise.

Fingerprint matching continues to require intense human expertise and intervention, despite the technologies and databases now available for fingerprint experts to draw upon. The experts make an identification when they see good enough similarity between two prints: similarities that can confirm that the prints come from the same source. These kinds of claims get made in the absence of any standard metrics for actually measuring or otherwise quantifiying similarity.

Instead, what fingerprint experts draw from is the expertise they have cultivated from their experience at looking at a large number of prints. This, they feel, provides them with enough of a grounds to match and distinguish between prints. They are rarely wrong – matching errors are very rare. They abide by a system of quality assurance, with a second examiner looking over and confirming the work of a first examiner.

SLIDE: Knowledge about Latent Print Identification

What a FP expert (believes she) knows:

What the academic critics (believe they) know:

Basis for identification

No objective measures

Dissimilarity/artifact

Insufficient testing

Errors VERY rare

??? (Some info emerging)

QA/Verification robust

???

No cognitive bias problem

Cognitive bias a concern

Permanence & Uniqueness

So what?

Identification to the exclusion of all others

Definitely overclaiming

Fingerprint experts believe that they can effectively distinguish between “artifacts” that are not a part of the print itself, as opposed to overlapping features common among a series of prints, which are read as markers of similarity and thus point to a credible match. Again, practitioners themselves believe that the errors they make are few and far between; some even believe that their method of reading prints has a zero error-rate.

Nowhere present in talk between fingerprint experts is the possibility of cognitive bias – to them, they adhere to and follow the scientific method. Fingerprints, they say, are stable: they don’t change over time and are unique to an individual. Due then, to the stability of the material evidence they work with, fingerprint experts can make an identification that is exclusive to the individual. A the end of every examination is the promise of making an identification that is exclusive to an individual: fingerprints that could not come from any other one in the universe.

Here is where the academic critics step in. Academics believe that the experts are not, as they see it, following objective measures, and that they are insufficiently testing for errors. Though the errors might be rare enough to seem non-existent, the mistakes that are made have been insufficiently studied, and are more common than the fingerprint experts make them out to be. Finally, to the academics, cognitive bias is of primary concern. Perfect identification matches are over-claimed.

At work, then, are competing models of what can be known and what can be certain. Each group (the fingerprint experts and the academics) tries to make its view into a totalizing gaze without giving space to any-other view. In the debate between the two, says Mnookin, “science and nonscience get wielded as weapons.” In this sense, their debates engage in boundary-work, defining and shifting the line between what gets to count as “science” and what should not.

Explicit talks of science raise the temperature in the room and alienates both sides, and fingerprint experts continue to assert that the work they do is rigorous and objective. Who gets to speak as an expert for the field of fingerprint identification? Are there critics within the boundaries of each of these communities, reflecting on their own techniques, and are these critics included or excluded in courtroom discussions of criminal evidence? According to Mnookin, such dissenting voices are in fact sometimes excluded, since the critics are oftentimes not considered to be veritable fingerprint experts.

In approaching the subject of competing claims to expert knowledge, the role of experience versus formal data troubles both sides. Whether experience has any legitimate rule remains an unanswered question. Mnookin, with her STS-training, finds herself in an extremely liminal position when encountering these debates and tries to mediate across these boundaries. At the same time, her training, she says, makes her equally anxious about the rhetoric of science by critics.

The Brandon Mayfield scandal presents a critical space of engagement, in which the fingerprint experts have had to give up a little bit about what they claim to know. Courts have largely ignored critics of fingerprint experts. But meanwhile hybrid figures emerge, fingerprint experts with PhDs who play an important role in creating a space for dialogue between both camps. Mnookin participated in a working group on human factors in fingerprint identification. Personal engagement created space of cross-talk and help to recognize the front stage and backstage of the debates between FP experts and academic critics: Situation and situatedness matters in legitimate ways – this is what creates more cross-talk. Later, Mnookin wrote a paper with co-authors from different groups with the aim of fostering engagement with each other. The paper was used in different, unexpected, and contradictory ways in courtrooms by either group.

This raises the question how we can move things between the inside and outside of the courtroom in order to recognize the legitimacy of multiple viewpoints here, in a way that also insists on it for evidence that is being used in convicting people.

Anne Pollock (‘07): Health Disparities and American Citizenship Claims

AC_Anne Pollock

Anne Pollock will discuss a subject that she has been familiar with since her time in the HASTS program, a theme that runs through many of her projects: racial disparities in health and health care. For her, this subject is an important starting point for thinking through race and racialness in America.

By October 2001 at the confluence of a number of local and national events, Pollock found herself thinking in new ways about how Americanness was currently at stake. The walkout at MIT in particular pushed her to begin thinking about the boundaries of racialness. Around this time, MIT held a series of talks on Technology and Self. Present at one of these talks – which just so happened to take place around the time of the anthrax mail scandal, was Eric Caplan from Pfizer. Pollock recalls him insisting, with anthrax on everyone’s mind, that anyone in the room could get Ciprofloxacin (Cipro) who needed it.

Pollock recognized that, as an empowered biocitizen, this would certainly be the case for her – accessing Cipro, in the event that she was exposed to anthrax, would not be a problem. At the same time, she realized that this was not the case at all for the postal workers who died from anthrax exposure. They had not been able to simply “go to their doctor at get Cipro” in the way that she could, and as the Pfizer representative had insisted so casually.

Even though we are a society that is infiltrated by pharmaceuticals, says Pollock, there are boundaries of access. One of the postal workers on Capitol Hill called 911 the hour before he would die from the exposure. He had already been to see his doctor, who had given him Tylenol and turned him away.

SLIDE: Transcript of Postal Worker’s 911 Call (Slide shows abbreviated version of transcript.)

Such an extreme example, says Pollock, points to the tie between access to pharmaceuticals and access to Americanness, or being able to access adequate pharmaceuticals and being able to count or qualify as “American.”

In her first book, Medicating Race, Pollock track heart disease and race investigating how the category of heart disease risk articulated race. The book center around the drug BiDil, released in 2005 to be used for the treatment of heart-failure in self-identified black patients. With BiDil, the FDA put its finger on a racial category. Yet Pollock believes that the way in which STS has traditionally framed critiques of this campaign – race and genetics – misses out on an important aspect of what’s going on. These kinds of projects are also about race and access to medicine. Black Americans with heart failure, after all, are a structurally underserved population, and there remains much to be examined at the social level beyond the genetic reinscription of race.

In moving away from pharmaceuticals, Pollock has focused her efforts on investigating the Scott Sisters case. The Scott sisters were serving double life sentences for a trivial crime in Mississippi. Their sentences, however, were eventually suspended, on the grounds of a very peculiar caveat: poor health. Their release was contingent Gladys Scott agreeing to donate her kidney to her sister, Jamie, whose severe kidney disease required daily dialysis and had reached a dangerous turning point. The governor of Mississippi issued a statement on their release, claiming that their incarceration was no longer necessary, and that the cost of maintaining their health was no longer a responsibility of the state.

For the Scott Sisters, biological citizenship was constituted on access to medicine. Significantly, the only people in the US with constitutionally guaranteed access to healthcare are prisoners. It is not ok, says Pollock, to withhold adequate health care from prisoners, while it is within legal boundaries to do so for anyone else. The prison system created the conditions for Scott’s poor health, while at the same time creating the conditions for having her health issues taken care of. Pollock characterizes the sisters’ release as conditional upon the “threat” of organ transplant.

Just as in the case of BiDil, Pollock believes that the Scott Sisters’ situation underscores a crucial component in discussions of health and race that STS otherwise fails to consider. “Our biological bodies are not just in our genes,” says Pollock. These are cases not just about race and genetics, but about race and bodies. And testaments to the importance of socially-based interventions to health disparities over purely pharmaceutical ones notwithstanding, we must remember that medical care too is a necessary site of social justice claims, rather than an alternative to it.

 

Jenny Smith (‘06): From Soup Nuts to Curry-Flavored SPAM, a History of the Science and Politics Behind American Food Aid

ACJ_Jenny Smith

The title of her talk aside, Smith will focus on more than just spam. Her discussion centers on a new research project on food and international development. She is a Russianist by training and her most recent book focussed on the history of the environment and technology. Yet concerns about food have always been on the “backburner,” so to speak.

Though many people have written about food, development, and American assistance in the developing world, there are gaps in such investigations: few have examined the history of emergency feeding.  The history of feeding in emergency situations is, in part, an American one, but Smith endeavours to tell a more international story.

Emergency feeding through, for example, soup kitchens has been around for centuries. Her investigation begins with the Soviet famine of 1921-22 in the Volga delta. It was the first event when outside experts were brought in to help. Herbert Hoover brought in an aid program based on techniques developed by military experts, church groups, and the American Red Cross. This famine in the Volga Delta played out as a mass event.

[Slide showing relief supplies sent from the US to the USSR to mitigate the famine.]

Her current project will study the science of feeding from this event in 1921 to hunger in the Democratic Republic Congo in 2011 where Plumpy’nut was distributed to children. This food is a product of milk, peanut, and oil hydrogen, deployed to feed people who are about to die with crisis on their hand. How did we get we from the “basic” supplies of the Volga famine that assumed the availability of kitchen, pots and spoons to a more self-service driven model, with children feeding themselves the hygienic and individually foil-wrapped Plumpy’nut in 2011 — what is the science behind it? Palatability is key: Plumpy’nut is quite sweet, so children enjoy and are therefore driven to eating it.

[Slide showing a child eating Plumpy’nut].

Slide: Ancel Keys, Minnesota Semi-Starvation Experiment, 1944-1945

Smith also wonders how have scientists studied starving people. It is not unprecedented for scientists to research what people need for re-nourishment in an extreme crisis situation. In the Minnesota Semi-Starvation Experiment of 1944-45, thirty-six American white-male conscientious objectors were put on a very low calorie diet for 24 weeks and monitored using various medical devices. Some of the subjects had psychotic break-downs, the health of most deteriorated, and some never fully recovered, suffering from permanent heart problems. After the war, the Nuremburg Code was adopted and such trials did not happen again.

Smith focuses on research being done on rats and Nigerians. Scientists study the living human experience of starving on populations of people that are starving, as well as on laboratory animals (she hints at a scientific era of “starving rats”).  In the late 1960s, a crisis in Nigeria lead to mass starvation among children; due to more stringent ethical medical guidelines, any treatment performed on children was expected to be therapeutic rather than purely experimental alone. Scientists were interested in exploring the long-term effects of famines through this case. Particularly, mega-NGOs like Oxfam tried to show that it is worth helping children caught up in a famine; that such aid is positive for the children’s development.

This initial work in the 1970s did its job almost too well. Companies realized that starving kids presented a kind of untapped consumer audience; getting into the business of nutrient products, such as  Pumpy’nut, appeared to be a lucrative endeavor. Smith is interested in how this research became part of a for-profit model of emergency feeding in the late 20th and early 21st centuries. In this context, she mentions an ongoing study of curry-flavored spam in Guatemala.

Jessica Wang (‘95): The Telling Case: Rabies Narratives, Autopsy, and Medical Community in Nineteenth-Century New York City

AC_Jessica Wang

Wang has moved quite far from her earlier research on science during the Cold War era and anti-communism in the US. Currently, she is working in the history of medicine. These days, she says, her career has “gone to the dogs”: her primary scholarly concern is the social history of rabies in 19th and 20th century in New York.

This projects touches on the social history of medicine, disease and public health, animals studies, human-animal interaction and the problem of human and animals living in the same public and urban space. The work she will present to us today is part of a larger interest in institutions and state power. Believe it or not, she quips, the politics of dog catching can speak to larger issues on power, statehood and the development of the American state.

Turning back to the dogs, Jessica describes how rabies autopsies functioned as sites in the making of medical communities. Physicians committed to autopsies as acts that would provide definitive diagnosis for rabies, even while autopsies did not reveal consistent evidence of disease.

Rather than giving a synopsis of her book she moves to the micro-historical level, focusing on to particular case history and what this reveals about 19th-century medical identity; in other words, exploring case narratives as a mode of representation and method of physicians’ self-fashioning.

In 1869, WB Rodman in Frankfort, Kentucky, described a case history of hydrophobia. The narrative itself and the meanings to be derived from this short, 5 page case narrative are quite complicate. This case history is not a neutral account of diagnostics reasoning and doesn’t pretend to be a “view from above.” Instead, it is quite a suspenseful narrative that underscores the patients difficult position, and how that position was perceived by the protagonist: the physician.

What unfolds is a third-person mystery tale of the patient’s descent into illness, along with the usual details of the case narrative (etiology, details about the patient’s life, and so on). He outlines the strange symptoms of this patient, and then shifts suddenly to the first person: enter the physician, the protagonist! Rodman discusses his earlier mistaken diagnosis (a heart problem? No. Raving lunacy? Not that, either). Finally, along with the help of his father (who was a physician himself), he witnesses the A-ha moment: his patient can’t swallow liquid. Diagnosis: hydrophobia!

Rodman and his father now knew they had a very special and rare case before them, so the other physicians in the city were called in. A collective assembly of doctors signals a narrative shift to the collective, passive voice: “It was decided,” the narrative continues, en masse, “to give the patient chloroform” although the patients’ symptoms made it impossible for him to physically imbibe it by any means. Symptoms notwithstanding, the patient denies having had any interaction with dog that would result in such an illness, but the physicians’ collective expertise reigns over the patient’s own story. Eventually, the physicians break down his resistance: when asked a second time, suddenly, he remembers how and where he was bitten, even demonstrating the slight scar on his finger that remained from the encounter.  In this moment of jarring his memory and realizing that the physicians are, in fact, correct, the patient suddenly begins to realize the gravity of his condition. He asks to see his family, and refuses with lamentation to even give them a final kiss goodbye, for fear of passing on his condition.

This melodramatic final deathbed scene is not the end of the story, but rather a narrative junction in the larger case history plot. After all, the story is not about the patient, but about the physician. The patients’ final moment is followed by the physicians own isolation, and this is where the tale actually culminates. For the first time, alone, the physician must witness the patient in ultimate suffering, without having any means to save or help him as he dies. This is the moment in which the physician reveals autobiographical information. The author of this case is a young doctor, early in his career. In fact, he was 24 years old at the time of examining John D. Sargent, perhaps working in the medical practice of his father. Here is a young physician confronted, for the first time, with a dying patient, grasping at any means to provide his patient with some help.

The patient’s death was quiet and completes an important rite of passage for the young physician. This narrative of the case and the way it resolved itself is a coming of age story: the physician emerges changed and seasoned, now with a renewed sense of what hydrophobia was, a Bildungsroman in 5 pages. More than that, by seeing a human being dying before his own eyes, he experience himself the physician’s final helplessness before death.

The allusion to the absence of any other doctors from the scene further heightens the dramatic power of this moment. Interestingly, the narrative remained silent as to whether any of the patient’s family members were in the room as he expired. Certainly, from an authorial standpoint, their presence would’ve been inconvenient. Thus, whether literal or figurative, the removal of all but doctor and patient compounds the doctor’s metaphorical isolation (that he is on his own, without parental tutelage, unable to draw upon his expertise to aid the patient, and so on).

This is a story how the young physician comes into his own – metaphorically and very much literally alone. The mature physician, his education completed alone with his books and medical dictionaries: this is the final tableau on which the story closes.

How does this one case history fit into the larger canon of case histories? While 19th century physicians embraced a didactic rationale for case histories, they still celebrated in the telling and swapping of stories of the odd case, delighting in the diverse and quite strange nature of medical practice, a way to build career and explore what it really means to be a physicians through the literary  construction of the physician.

The narrative conventions of the case history certainly didn’t prevent the physician from inserting themselves into the scene. Hydrophobia case histories were particularly flexible, allowing physicians multiple possibilities for self-reflexion.

Case histories remain an important genre. This speaks to the continued fascination of the “odd case,” and on-going interchange between experience and identity that remains a central part of telling of the case and the cases ability to instruct and entertain.

 

Q & A

Moderator Lan Li points to some overlapping themes: expertise and decision-making, rites of passage of physicians and other experts, questions about what one is allowed to “ingest” and the entanglement of industries and social identities.

Evelyn Fox Keller asking Jenny describes George Tannon’s talk on the Russian Revolution and Russian famine and debates about whether or not to provide help would have a hand in l breaking the revolution down. Are there comparable stories in recent history?

Jenny answers that France and the US and Britain all have various takes in wanting to or not wanting to intervene in a crisis and give support to either side. Focusing on France and the formation of Médecins sans Frontières, it seems that separating politics from famine relief is almost impossible. In the case of Biafra: people using hunger as a weapon, working to the advantage of rebel groups. In short: politics are always present when we approach these kinds of crisis situations – they play a large role in the case would like to focus on.

Harriet Ritvo asks Jennifer: In making her set of two opposing positions in the case of fingerprinting, both sides assume that the product is working as best as it can. In a recent case of a drug lab in Massachusetts: Annie Dookin did many bad things, but there were a series of other failures that allowed things to happen as they did. Are there any accounts taken in terms of the possibility of radical system failures – failures on a different levels?

Jennifer says well, yes and no. What happens is that until very recently, the only available rhetoric in fingerprinting when it came to making t mistakes was the “bad apple claim”: this fingerprinter, through incompetence or worse, screwed up. Mistakes are seen as the fault of a single person, not of an entire system – of an individual’s competence or morality.

What happened with Brandon Mayfield in the Madrid Bombing Case? He was held as a material witness on the basis of a fingerprint, despite his insistence that he had never left the country. Four fingerprint examiners (including a court appointed one and three top FBI folks) all disagreed: they thought it was a match, so there was no grounds to claim any “bad apple” fingerprinters. Rare extenuating circumstances aside (uncanny resemblance between two prints) this meant that they needed to look beyond singular person competence and concede that perhaps there is some more system-oriented issues, or issues at the scale of the system.

There’s been an new openness to thinking about this question of scale, though the rhetorical space has been hard to find. Human factors analysis has played a role as an acceptable language for engaging with systems, but there is still a strong desire to see errors (notwithstanding other cases) tas local rather than systemic, as personal rather than structural.

Shira Shmuely to Jennifer: Courts don’t really worry about this issue. The controversy seems to be between between professional experts and academics critics.  What is the position of the courts?

Jennifer: Courts tried to exclude the evidence and limit statements that experts make, naming it as opinion and acknowledging the problematic that way. There have been all these challenge: the courts have honed their doctrine to assess expert evidence for liability, to assess whether this form of evidence is reliable.

The courts, through a series of events, in many jurisdiction, have honed their doctrinal responsibility to assess expert evidence for reliability. Judges are in this position where they’re supposed to determine whether or not this evidence is reliable. But the courts have been using fingerprint evidence for almost a hundred years, despite the fact that it is messy and weird (from the perspective of the prosecutors) to do anything other than business as usual.

Few courts that have excluded it or limited, but this is not the dominant view.The judges have not been particularly persuaded by critics.

The problem is that, for judges, the court is their stage. If you could come into court with a perfect form of evidence, why would you engage in research that at most would show that you were LARGELY right? There’s not a lot of incentive to do that. In a way, this is just as much of a story of legal failure.

Anya Zilberstein raises two questions, one for Jenny and one for Jennifer. It seems, she says, that Jenny implied the relationship between agricultural landscapes and environments is that there are surpluses and (albeit horrible) market opportunities, in places where starvation and war are common. Hornel says: here’s a corporate opportunity to sell off a surplus in a newly synthesized form. It seems like there’s already a landscape that’s the product of US AID policies, but is there a reciprocal effect? Do these policies change the landscapes or intensify production?

To Jennifer, she wonders about the role of digitization in fingerprinting. How does digitization and increasing pushes to digitize figure into debates about “ink” and the experts that know how to read fingerprints that way? Has this brought a whole new group of people into the debate – people writing the programs, for example?

Jenny: There has been some great scholarship in the past few years on sending off surpluses, which sets up a situation where farmers make different choices about which crops to raise. Emergency feeding is more of a one time aid package situation, which is watched over by a different branch of the government. There has been great work done on the long term consequences on chronic aid and chronic surplus donations, so she is hoping to look at the impact of these emergencies, herself. There are certainly more emergencies now than there have been before.

Jennifer: Her academic duty to get a new iphone to mess around with the fingerprinting app – the landscape of fingerprinting is itself certainly changing. The prints being compared, whether old fashioned or medium high tech digital prints, are taken in more controlled situations and are more complete. In this way, using computers can help a great deal in the job of matching prints. If you’re doing a criminal identity check, you can do this in a lights-off way: autonomous technology takes care of making the match, without any human presence.

But we’re not quite there yet. The fingerprint examiners are being pushed to automate, to create algorithms for latent print identification – these kinds of programs might put them out of a job. They’re also pressured by more time consuming and more expensive efforts of fingerprint identification. All of these could speak to their defensive response.

David Singerman asks a question for Jenny about helicopter imports, how the food gets delivered, and who gets credit for it. At what point did Americans stop and did other people taking care of the pick up? Are there Americans actually in the Soviet Union delivering these foods? Again, what is technology of delivery and who gets credit for delivery? He offers an anecdote of aid shipments being reattributed from US to USSR with a simple stenciled addition of “SR.”

Jenny: In the case of Volga famine, there were Americans on the ground. They became part of international operations to get into country. The American Friends Society was all about helping people and Hoover aligned himself with them. Here, there were claims of impartiality alongside critics pointing out extreme cases of partiality; there was plenty of American spy stuff going on in these contexts. .

Attribution is often a sticking point. Now aid is often labeled something like, “This food is a gift by the American people.”

Jennifer directs a question to Jessica:

“You pointed to the patient’s denial that he was bit by a dog alongside a very detailed description. Here, we have the patient narrative versus the symptomatology. How do you understand the shifting and dialogic nature of patient narratives and symptom expression?”

Jessica responds: By the second half of the 19th century there are handbooks on how to take a case narrative. Your only real source of information is the patient, and patient testimony is important as an ultimate authority of one’s own experience and one’s sense of what is going on the in the body. On the other hand, the physicians authority is there in the room as well. You also have the rise of, in the second half of the 19th century, objective measures outside of the patient: the stethoscope, tools thought to contain physiological information. Outside of those techniques, you have the problem of the doctor’s authoritative expert gaze: how do you balance what the doctors sees, through the lens of their expertise, versus what the patient experiences? The balance of power changes once the doctor reaches certain diagnosis, and all that they need is corroboration from other physicians: we know you have this disease, they will collectively tell the patient.

Even the most neutral case narratives coming out of hospitals, written off of standardized patient charts, though trying to be objective representations that remove the knower from the process of knowing still maintain the physician’s gaze. Whether or not the person in question is alcoholic will affect the perceived “objectivity” or truth or authority of the patient’s testimony. This also gets worked into the authoritativeness of the patient’s diagnosis.

Etienne Benson directs a question to Anne Pollock on the attribution of responsibility for ill health among patient populations. Who is to blame or what is to blame: the individual, their poor social environments, or the prison environment itself? Moreover, given that many prisons are run privately, are there any opportunities for prisons to profit off of sick prisoners?

Anne answers that the case she focused on is a little special. The sisters were quite young when they first entered prison, and they were women, though it is mentioned that Jamie (one of the sisters) is a smoker and needed to quit smoking before she could be a donor. Here, we see some moral attribution creeping in – “you’ve chosen to smoke, after all!” But Anne hasn’t seen it mobilized in this kind of way – it’s not that the villain is most identifiable by sheer virtue of being a smoker.

Cigarettes play an important role in the prison economy and the prison way of life. Obesity, too, could be blameworthy. But this case, instead, has a lot to do with their identities as mothers and grandmothers, that they were young when they went in – all of these factors inhibit this blame-centered narrative from coming into the picture.

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