Medical Humanities Blog

On Ghostwriting Policies & Elite Academic Medical Centers

Jeffrey Lacasse (Ariz. State Univ.) and Jeffrey Leo (Lincoln Memorial University) have published an article in PLoS Medicine entitled Ghostwriting at Elite Academic Medical Centers in the United States.  Like all articles in PLoS Medicine, the article is available full-text, open-access.  The article lacks an abstract, but here is an excerpt of the Background section (citations omitted):

Medical ghostwriting, the practice of pharmaceutical companies secretly authoring journal articles published under the byline of academic researchers, is a troubling phenomenon because it is dangerous to public health literature is thus a serious threat to public health . . .

In 2009, the Institute of Medicine recommended that US-based academic medical centers enact policies that prohibit ghostwriting by their faculties.  However, to date, there has been no systematic assessment of ghostwriting policies at academic medical centers. Since US-based academic medical centers generate biomedical research for a worldwide audience, we chose to conduct the first such investigation on elite US-based academic medical centers. Our methods are shown in Box 1. We sought to describe the current policy situation at US-based academic centers and then to propose an ideal ghostwriting policy.

Lacasse and Leo have made a career out of simultaneously debunking the chemical imbalance theory of depression and illustrating its prominence in DTC marketing, mass media, and popular culture regarding depression and mental illness.

Leo, it should also be noted, was the central figure in a recent publication ethics controversy involving the Journal of the American Medical Association.

The current article, of course, is recommended.

(h/t Pharmalot)

Review: Graham Mooney, Jonathan Reinarz, eds. Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting. Amsterdam: Rodopi, 2009

H-Net Disability (history) listserv* has posted an excellent book review of an important new book entitled Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting, eds. Graham Mooney, Jonathan Reinarz.

Here is the first paragraph excerpted:

Graham Mooney and Jonathan Reinarz’s Permeable Walls is the first collection entirely devoted to the history of visiting patients in the hospital and asylum setting, neatly deflecting attention away from a more traditional focus within the history of medicine upon the experiences of patients and doctors within the institutional setting. This is an important contribution to the historiography, given that visiting patients, relatives, and friends in medical institutions is a universal practice worldwide, and that people tend to visit the hospital as a visitor more frequently than they do as a patient. Consideration is therefore given to an experience that is not so much part of the institution, but one that is periodically and momentarily drawn into its ambit. Throughout the collection, visitors are presented as an understudied constituency in medical history, and their experiences are explored in broad social, cultural, and geographical perspectives. It is shown, for instance, that discussion of the wider significance of visiting in fact draws attention to issues such as urban governance, philanthropy, the public sphere, civil society, and citizenship. This is all achieved via discussion of the different types of visitors: patient visitors, public visitors, house visitors, and official visitors.

The entire review may be read open-text, full-access here.

*(Disclosure: I am a book reviewer for H-Net-Disability).

On Principlism, Resource-Poor Communities, and Social Justice

Jacquineau Azétsop (Faculté de Médécine Teilhard de Chardin) and Stuart Rennie* (University of Cape Town & University of North Carolina - Chapel Hill) have an outstanding new article forthcoming in Philosophy, Ethics & Medicine (full-text, open access) entitled Principlism, medical individualism, and health promotion in resource-poor countries: Can autonomy-based bioethics promote social justice and population health?

Here is the Abstract:

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, autonomy-based bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy.

By a "sociological explanation of disease causation," the authors are referring to the overwhelming evidence that patterns of population health in both the global north and the global south are primarily determined by the social and economic conditions in which people live and work.  This, of course, is a central feature of both my own work and MH Blog in particular.

This is a masterful article, although, if anything, I think the authors understate the case against the utility of autonomy-based bioethics for promoting social justice and population health. 

Highly recommended.

*You can read more of Rennie's fine work at his excellent blog, the aptly titled Global Bioethics Blog.  

On Dehumanization & the Humanities: Part II of II

See here for Part I.

Continuing on with Slouka's analysis, we left off by explaining that even those at the vanguard of pushing for greater attention and resources for education frame their case in economic terms.  Says Slouka, "[i]t can be touching to watch supporters of the arts contorting themselves to fit."

It would be bad enough on its own terms to reduce the value of education to the production of capital, but what makes it far worse is that it is a total corruption of the studia humanitatis itself, the entire point of this was to teach us how to be better human beings, to cultivate virtuous practice.  To say this is not to imply that the humanists and those fortunate enough to receive a humanist education were unconcerned with the practical world.  Quite the contrary; the measure of virtue was the way in which it produced betterment in the actual, daily interactions of community and society.  I have remarked on several occasions that if I were to attribute an ethos to the studia humanitatis, it would be "practical engagement."  But such engagement, in the service of virtue, is a galaxy far far away from viewing the primary role of education as increasing capital.

Yet, the able reader wants to know, how can I claim with a straight face that the humanities are characterized by a focus on practical engagement? Examining the state of the humanities in undergraduate and graduate education does not inspire confidence that due attention to practical engagement is the norm.  Slouka is well aware of these concerns, and reserves some of his sharpest criticism for his fellow humanities scholars and teachers:

No assessment of the marginalized role of the humanities today is possible without first admitting the complicity of those in the fold.

[ . . . ]

[University humanities scholars], in a pathetic attempt to ape their more successful colleagues in the sciences, have developed over time their own faux-scientific, isolating jargon, robbing themselves of their greatest virtue, their ability to influence (or infect) the general population. Verily, self-erasure is rarely this effective, or ironic.

Though I have both a background and facility in the kinds of critical theory that I believe Slouka is targeting, I have intentionally chosen not to frame my own scholarship in such style.  The reason, again, is my commitment to the Aristotelian question, to what I perceive as the ethos of the humanists themselves.  If the point of the humanities, historically understood, is to cultivate virtuous practice through practical engagement with the world, adopting a style of thinking and writing that is basically dense with impenetrable jargon virtually ensures that nothing I say or do as a scholar will have any meaning to all but a few hundred people (at most) around the world.

Again, the question looms: what kind of a person do I want to be? I have no delusions of grandeur, I hope.  But I cannot knowingly and intentionally choose a life as a scholar which makes even more likely the notion that little I say, teach, or write about will accomplish much in terms of practical engagement.  Perhaps in some fields of inquiry or disciplines in the humanities, the choice of style and discourse is more acceptable, but I honestly feel that when one's concern is health and illness in society, such a luxury, if it is indeed a luxury, is gone.

We humanities scholars either want to help, or we do not.  And it is hard for me to understand how much help we can be if we choose to communicate in ways that can barely be understood by those whom we should most want to reach (whether scholars and educations from other disciplines and traditions, or illness sufferers, caregivers, etc.).

All that said, why study the humanities? Why should we care that they are marginalized from both within and without? Defunded, declined, denied?

Answers Slouka:

The case for the humanities is not hard to make, though it can be difficult—to such an extent have we been marginalized, so long have we acceded to that marginalization—not to sound either defensive or naive. The humanities, done right, are the crucible within which our evolving notions of what it means to be fully human are put to the test; they teach us, incrementally, endlessly, not what to do but how to be.

Note, of course, that this is simply Aristotle's question recast in Plato's terms: how shall we live? IMO, Slouka is absolutely correct that assessing how we shall live is and has been the raison d'etre for the humanities for thousands of years; it is unquestionably the central theme of the studia humanitatis.  Note also the implication that such a task is perforce value-laden and political.  I have little patience for the frequent calls to avoid politicizing health policy, nor for the same calls with regards to teaching and scholarship.  There are, to be sure, some very real concerns that I imagine opponents are referencing in such a call, but the resolution is to act on those concerns (i.e., closed-mindedness, exclusion of viewpoints) rather than launch a quixotic and absurd quest to strip from an inherently, intentionally political, value-laden activity politics and values. 

Anyone with the slightest awareness of who Socrates was and what happened to him cannot possibly believe the legitimacy of the notion that practitioners of the humanities should strive to remove politics and values from their work (as if they can be eliminated or even minimized to any great extent).  Slouka explains it thusly:

They are thus, inescapably, political. Why? Because they complicate our vision, pull our most cherished notions out by the roots, flay our pieties. Because they grow uncertainty. Because they expand the reach of our understanding (and therefore our compassion), even as they force us to draw and redraw the borders of tolerance. Because out of all this work of self-building might emerge an individual capable of humility in the face of complexity; an individual formed through questioning and therefore unlikely to cede that right; an individual resistant to coercion, to manipulation and demagoguery in all their forms.

Slouka moves on to conclude that the humanities are critical to forming vibrant democracy, and to building democratic values.  There is likely some truth to this, but I generally do not share many theorists' enthusiasm on such grounds, mostly because I concur with Churchill that democracy is absolutely the worst form of government imaginable except for all the other ones that have ever been tried.  Nor do I agree for one moment with Slouka's contention that the practice of science is politically neutral.  This is both conceptually and empirically untenable, neither the human enterprise of scientific practice is apolitical, nor are the uses to which it is put.

Nevertheless, these are relatively minor quibbles.  So there, gentle readers, you have it.  A masterful essay, truly.  I am not remotely hopeful that the low cultural value we assign to the humanities will be staunched or reversed any time in the near future.  The reasons why I am pessimistic have much to do with the reasons why science and medicine enjoy such dominance, why they are the great social legitimizers of contemporary American and Western society. 

That scientific perspectives enjoy such dominance is, as Slouka reminds, only a problem because there are some things a scientific perspective simply is not designed to illuminate.  Engaging the deep questions -- how shall we live? what kind of people do we wish to be? -- is primary among them.  Which is not to say a scientific perspective is irrelevant to these questions, but merely that our capacity to reflect deeply and meaningfully on how best to live, and then to do so, is in large part a function of our recourse to a peculiarly humanities-based point of view.

Thoughts?

On Dehumanization & the Humanities: Part I of II

Mark Slouka has a stunningly good essay on our culture's general disdain for the humanities in favor of all things numerative and scientific.  The entire article must be read in full, and is so good, it will take me two separate posts to highlight his discussion full.

Slouka's perspective cuts to the very heart of the medical humanities, of this blog, and of my own professional and personal identity.

As I move through both this post, and/or as the good readers of MH Blog read Slouka's thoughts, it is worth disclosing that in an entirely literal sense, I am driven by Aristotle's foundational question: what kind of a person do I want to be? I am particularly interested in the social version of this question: what kind of people do we want to be? 

Slouka opens his essay:

Many years ago, my fiancée attempted to lend me a bit of respectability by introducing me to my would-be mother-in-law as a future Ph.D. in literature. From Columbia, I added, polishing the apple of my prospects. She wasn’t buying it. “A doctor of philosophy,” she said. “What’re you going to do, open a philosophy store?”

[ . . . ]

It’s a play I’ve been following for some time now. It’s about the increasing dominance—scratch that, the unqualified triumph—of a certain way of seeing, of reckoning value. It’s about the victory of whatever can be quantified over everything that can’t. It’s about the quiet retooling of American education into an adjunct of business, an instrument of production.

Indeed.  To reduce such eloquence to a soundbite, Einstein will do: not everything that can be counted counts, and not everything that counts can be counted.  For a more scholarly take on the undeniable dominance of quantification in American culture, see the work of Theodore M. Porter.

During graduate school I took a course on aging in context of the medical humanities.  In that course, I read a number of works which began to convince me that Western society's turn to using productivity as a paramount criterion of value is unfortunate at best and pernicious at worst.  And here, let me emphasize that I use the term value in its proper, classical, humanistic sense.  Value, not measured and quantified, but value in the Aristotelian spirit, read as an account of our social lives, our polis, our living and dying.  The immensely powerful trope in which productivity defines one's social identity has devastating consequences for elderly persons in our society, because retirement, sickness, or injury result not just in the need for a radical transformation of self, but suggest that the economically unproductive life is not worth living.

This is not what Socrates had in mind.

More from Slouka:

What is taught, at any given time, in any culture, is an expression of what that culture considers important.

[ . . . ]

In our time, orthodoxy is economic. Popular culture fetishizes it, our entertainments salaam to it (how many millions for sinking that putt, accepting that trade?), our artists are ranked by and revered for it. There is no institution wholly apart. Everything submits; everything must, sooner or later, pay fealty to the market; thus cost-benefit analyses on raising children, on cancer medications, on clean water, on the survival of species, including—in the last, last analysis—our own. If humanity has suffered under a more impoverishing delusion, I’m not aware of it.

Quite so.  I have tried, in my own feeble way, to echo Slouka's concerns in my consistent warnings of the error of reducing discussions of health policy to cost-benefit analyses (or any other descriptive program).  It is, of course, important and relevant to understand how patterns of health, illness, and human suffering are shaped by costs and benefit.  But never can the collective decisions we do and do not make -- our answers to the beacon of Aristotle's question -- be reduced to such programs, for they cannot absolve us of the awful responsibility to decide which pathways and practices are virtuous.  And efficiency is not a cipher for virtue, which means sometimes virtue would require us to act inefficiently.  Yet in my own little sphere, the conversations so frequently end once the calculations have been performed, and the costs and benefits have been lined up, when in fact, this is simply the beginning of the conversation.  Or at least, it should be.

Slouka:

The questions are straightforward enough: What do we teach, and why?

[ . . . ]

Our primary function, in other words, is to teach people, not tasks; to participate in the complex and infinitely worthwhile labor of forming citizens, men and women capable of furthering what’s best about us and forestalling what’s worst. It is only secondarily—one might say incidentally—about producing workers.

I would not even put the task of producing workers as worthy of second order status, or if I would, I would require an extremely large chasm between the normative importance of the first-order goal Slouka articulates and the need for producing workers.  Even the discourse on the crisis of education is accounted for in terms of labor and productivity:

From the local PTA meeting to the latest Presidential Commission on Education, the only subject under discussion, the only real criterion for investment—in short, the alpha and omega of educational policy—is jobs. Is it any wonder, then, that our educational priorities should be determined by business leaders, or that the relationship between industry and education should increasingly resemble the relationship between a company and its suppliers, or that the “suppliers” across the land, in order to make payroll, should seek to please management in any way possible, to demonstrate the viability of their product?

Thus concludes Part I.  In Part II, I will address the case Slouka makes for the humanities.  Needless to say, please don't wait for my bare attempts at exposition.  Read Slouka.

(h/t Leiter Reports)

On the Very Idea of Public Health

An early candidate for "Article of the Year" in 2010 is Amy Fairchild, David Rosner, James Colgrove, Ronald Bayer, and Linda Fried's piece entitled The EXODUS of Public Health: What History Can Tell Us About the Future.  Published in the January 2010 (vol. 100, no. 1) issue of the American Journal of Public Health, here is the abstract:

We trace the shifting definitions of the American public health profession's mission as a social reform and science-based endeavor. Its authority coalesced in the late nineteenth and early twentieth centuries as public health identified itself with housing, sanitation, and labor reform efforts. The field ceded that authority to medicine and other professions as it jettisoned its social mission in favor of a science-based identity. Understanding the potential for achieving progressive social change as it moves forward will require careful consideration of the industrial, structural, and intellectual forces that oppose radical reform and the identification of constituencies with which professionals can align to bring science to bear on the most pressing challenges of the day.

The authors are core faculty at Columbia's Center for the History & Ethics of Public Health, and are unquestionably among the most important public health scholars in the U.S. today. 

This article is a tour de force.  It provides a succinct snapshot of the evolution -- or, to the critics' mind, the devolution -- of public health in the U.S. from its origins in the mid-19th century to the present.  While the authors eschew outright polemic, their perspective is never hidden, as the title itself makes clear (an "exodus" of public health).  Where did this flight originate? And to where is it going?

You'll have to read the article for the entire story, but the basic idea is that U.S. public health practice has fled from a commitment to population health in terms of social justice to amore individualized, scientistic model of public health that is decidedly noninterventionist:

We argue that the death of progressivism and the advent of the conservative political and social environment of the 1920s pushed public health into the laboratory and the university and away from the traditions that had once been central to its identity . . . the growing power of medical science and narrowly defined "efficiency" continued to push public health away from its reformist roots.

The basic contours of this narrative should not be news to public health scholars, but rarely has it been as carefully, as succinctly, and as expertly related as it is in this article.  Of course, the (normative) political stance of this history, and of the others, is quite apparent from this quote.  Indeed, that is precisely the point, given that fin-de-siecle and 20th-century public health practitioners grew decidedly uncomfortable with the overtly political stance of the reformist models championed by figures like Engels, Virchow, and W.P. Alison.*  The gaze of the laboratory and the clinic on the discrete pathologies deemed to cause disease provided a powerful channel for the reluctance to endorse social and class reform.  Indeed, they still do, which is partly why I maintain that understanding the power of the visible lesion or pathology in causing illness is a critical desideratum for the medical humanities.  Fairchild et al. explain:

. . . the public health community embraced bacteriology with its focus on the laboratory rather than the social and environmental context, as an authoritative science that did not require political alliances: science spoke for itself.

The idea that scientific evidence "speaks for itself" is, IMO, utter nonsense, though I certainly agree that the belief that it does is sadly ubiquitous, today no less, and perhaps more than it was a century ago.  Anyone remotely familiar with the terrible problems in translating evidence into practice (estimates of evidence penetrance into clinical practice hover in the low end of a range from 10-40%) could immediately repudiate the claim.  I also have little patience for the frequent calls from all corners to avoid politicizing health care, public health, or science.  All of these endeavors, like any human enterprises, are irreducibly and inexorably political.  Leigh Turner authored an excellent recent article in which he demonstrated the numerous errors and incoherencies of the claim that "science/health/health care/public health should avoid politics."  Of course, there are certain political beliefs, acts, or practices which are and should be ripe for criticism by anyone concerned with the ethics of health and medicine, but to say the latter is quite different from the grandiose claim that science should avoid politics.

Engels and Virchow, to name but two, would either have rejected, ridiculed, or both the idea that advancing population health should be attempted by means as apolitical as possible.  This, I take it, is part of Fairchild et al.'s point.  They show beyond a shadow of a doubt that the decision to pursue a decidedly noninterventionist model of public health is absolutely political, reflecting a number of social, cultural, legal, and economic beliefs, assumptions, and concerns.  Deciding on relative priorities amidst scarce resources is an irreducibly political decision, and it makes little sense to me to pretense to the contrary.

Of course, it does not follow that any particular political or normative stance with regards to the future of public health is persuasive to any particular stakeholder.  But once we begin by accepting that our public health practices are fundamentally political, I think we may be somewhat closer to a qualitatively better discourse regarding which choices we ought to prioritize.  Even if I am wrong in this and the discourse is unimproved, there is, I think, value in shining some light on the choices we are making, and the consequences therein.  Discussing related matters in context of rhetoric, a mentor of mine suggested that one should not underestimate the power of shame as an impetus to positive action.

In any case, read Fairchild et al.  Thoughts, as always, are welcome.

(h/t Rick Lippin)

(*Sidenote: Though Fairchild et al. have forgotten more than I will ever know about the history of public health, Christopher Hamlin's work does make clear the danger of presuming, at least as to the U.K., that the Chadwickians were motivated by a strong concern for social justice and vulnerable classes.  Quite the contrary, in fact, Chadwick and many of his supporters were primarily interested in sustaining the existing inequitable class structure.  I am not certain whether this British history corresponds to the state of U.S. public health in the 19th century, but it is worth noting as a question).

Call for Submissions: Atrium

Atrium, which is one of the very best open-access ethics & medical humanities journals out there, has issued a call for submissions for Issue 8 (Summer 2010).  Here is the Call:

ATRIUM Call for Proposals (Theme: "Happy")
Deadline for proposals: February 1, 2010
Article deadline for accepted proposals: March 15, 2010

The theme for Issue 8 (Summer 2010) is "Happy." ATRIUM encourages potential authors to think creatively about broad interpretations of theme. For example: Does the concept of happiness have any relevance to medicine? How is pleasure a factor in medicine, illness, bioethics, or medical humanities? What's the role of emotion, affect, or the presentation of self? How should we define "patient satisfaction"? Are our students happy? Does it matter? What do you love about your work, where's the joy in medicine today? If you're not happy, what needs to change?

Proposals must be submitted by February 1, 2010. Proposals will be evaluated by February 15 and full articles for accepted proposals will be due by March 15, 2010.

________________

(h/t Lit&Med_ASBH listserv)

The latest issue (no. 7) of Atrium, featuring a particularly heart-wrenching contribution by David Morris, is available for download here.

On the Body In Medical Culture

There is a nice review up on H-Net of a new anthology entitled The Body in Medical Culture.  Here is an excerpt:

Within The Body in Medical Culture, Elizabeth Klaver and her contributors engage with themes related to how concepts and constructions of the body ultimately shape people’s experiences of agency and objectification within medical culture. It is argued throughout that the medicalized body is central to the work of doctors, nurses, medical examiners, and other professionals as an object of scrutiny, and that these groups mediate broader cultural understandings of pathology, illness, and physical transformation during their interaction with the body. Metaphors and models of the body are frequently used to understand medical phenomena, research, and diagnosis. Klaver carefully situates her collection at a mid-point between culture and medicine, adopting a constructivist realism approach, which suggests that an external reality exists outside of cultural representation. In other words, she recognizes a place for the body’s materiality as distinct from the medicalized body.

The review is recommended, and though I have not yet read the book, I daresay that is worth reading as well.

(h/t H-DISABILITY listserv)

On "Cholera Forcing"

In the November 2009 issue of the American Journal of Public Health, Christopher Hamlin (History, Univ. of Notre Dame) has authored a stunningly good article entitled "Cholera Forcing": The Myth of the Good Epidemic and the Coming of Good Water.  Hamlin is one of the preeminent historians of public health in the English-speaking world, and his work is nothing short of an inspiration for me.  Here is the Abstract:

It has been frequently claimed that cholera epidemics, both in the 19th century and today, were and can be the key stimulus for procurement of safe water and sanitation, an idea that I call "cholera forcing." "Technology forcing" refers to imposition of exogenous factors that suddenly make possible achievements that had not seemed so; cholera has been seen in this light. I argue that this view oversimplifies and underrepresents the importance of industrialization in securing water supplies. Careful study of the financial, political, and administrative foundations of such changes will be more fruitful.

Even by the absurdly high expectations I have for his work, this article is a tour de force.  Combining penetrating historical insight of public health history and ethics with an unbelievably acute assessment of the mechanics of past and present public health policy and policymaking, the article is a paragon for understanding the significance of the humanities in context of public health and public health policy.  (For more on this subject, see generally this outstanding article by Alison Bashford and Carolyn Strange, and this project headed up by Simon Szreter).

In any case, I cannot recommend both this article and Hamlin's body of work highly enough.

On Prevention & Social Policy

Longtime readers of MH Blog are likely familiar with my vexation regarding the typical features of the debate over prevention in context of health.  Namely, the kind of prevention that interests me -- and, I believe, that is most firmly rooted in a compelling evidence base -- is generally not the kind of prevention that is wrangled over in the current "discourse" over health care reform.  The kind of prevention that interests me relates to social policy, and involves creating or remediating existing conditions in ways thatwe have reason to believe will facilitate health over the lifespan.  These kinds of social policies suggest intensive investment of resources extremely early in the lifespan, and therefore operate on a paradigm that is entirely different from the preventive services that occupy virtually all of the political discussion on the topic.

Thus, I am pleased to recommend a short article on the topic by Erika Blacksher* (The Hastings Center) entitled Health Reform: What's Prevention Got to Do With It? Succinct and eloquent, Dr. Blacksher adduces similar points.  Here is an excerpt:

A recent poll found that an overwhelming majority of Americans from across the political spectrum think prevention should be given priority in health reform. Given its intuitive appeal, that result is not surprising. Who could be against the idea of investing in keeping people healthy? But as it turns out, prevention has its detractors. The debate turns on questions about its exact meaning, whether it is cost-effective, and the complexity of the enterprise.

Like most Americans, I am a fan of prevention. My view of what prevention is, however, may not be widely shared. Prevention to my mind means assuring that all persons are able to live in safe, clean houses and neighborhoods; eat healthy foods; socialize with family and friends; get exercise; rest and manage stress.

Highly recommended.

*Disclosure: Dr. Blacksher is a colleague of mine, and we have tentative plans to collaborate in the near future.