Tag: Life

1Introduction

1.1 Definition of Palliative care

According to the WHO, Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.

Palliative care provides relief from pain and other distressing symptoms, affirms life and regards dying as a normal process, and intends neither to hasten nor to prolong death.2 Palliative care integrates the psychological and spiritual aspects of patients care, and offers a support system to help patients live as actively as possible until death. It also offers a support system to help the family cope during the patient’s illness and in their own bereavements. In many countries, the terms hospice and palliative care are used interchangeably to refer to the support provided to people with little or no prospect of cure.3

In the United States, a distinction is made between general palliative care and hospice care, which delivers palliative care to those at the end of life; the two aspects of care share a similar philosophy but differ in their payment systems and location of services. Whereas in the United Kingdom, this distinction is not operative; in addition to specialized hospices, non hospice-based palliative care teams provide care to those with life-limiting illness at any stage of the disease.

According to the Scottish Partnership for palliative care, palliative care is the term used to describe the care that is given when cure is not possible. The word comes from the Latin “palliatus”(covered or hidden with a cloak) and is used to mean “relieving without curing”.4 Although palliative care is historically associated with later stages of cancer, it is now established that palliative care should be a routine part of care for those living with and dying from a wide variety of non-malignant conditions, such as dementia, heart failure, Huntington’s disease, motor neurone disease, multiple sclerosis, muscular dystrophy, Parkinson’s disease, renal failure and respiratory failure among others.

General palliative care is an integral part of the routine care delivered by all health and social care professionals to those living with a progressive and incurable disease, whether at home, in a care home, or in hospital.4 Specialist palliative care is based on the same principles of palliative care, but can help people with more complex palliative care needs. Specialist palliative care is provided by specially trained multi-professional specialist palliative care teams and can be accessed in any care setting.

1.2 Public health context of palliative care

Public health approaches to palliative care have a valuable contribution to make in understanding and developing community capacity related to , dying, loss and care acknowledging that carers of the dying and bereaved are an important group who have their own significant needs in end -of-life care.5 Primary care has a vital role in delivering palliative care. 6,7 In most developed countries more people die in hospital than at home 8,although substantially more people would prefer to die at home.9 Primary care professionals play a central role in optimising available care, but they often lack the processes and resources to do this effectively.6,10 The Gold Standards Framework (GSF) for community palliative care 11 is a primary care led programme in the United Kingdom that is attracting international interest.7 The framework enables general practitioners and community nurses to optimise practice by providing guidance through workshops and locally based facilitation on how to implement processes needed for good primary palliative care. It is supported by a plethora of practical tools, guidance documents, and examples of good practice.12 It is regarded by many as “the bedrock of generalist palliative care”. GSF is recommended as best practice by the Department of health End of life care strategy, NICE, Royal College of General Practitioners, Royal College of Nurses and other major policy groups.

1.3 Care pathways in palliative care

A care pathway is a plan of how someone should be cared for when they have a particular medical condition or set of symptoms. There is increasing evidence that using an integrated care pathway to manage care at the end of life is good way to implement and monitor best practice, and to standardise care in a variety of care settings. The use of pathways to manage the care of dying patients has gained considerable support from the clinical teams who have used them, as there is evidence that use of such pathways improves the quality of care in the last days and hours of life. A number of end of life care pathways have been developed but the first and most well known is the Liverpool Care Pathway for the Dying Patients (known as the LCP).13

A number of other pathways are available in relation to supporting the care of dying patients:

– Pathway for Improving the Care of the Dying (PICD) (Australia)

– Palliative Care for Advanced Disease (PCAD) pathway (USA)

– Department of Veteran’s Affairs (DVA) Palliative Care Clinical Pathway (Australia)

– Gold Standards Framework (GSF) for community Palliative Care (UK)

– Preferred Priorities for Care Plan (PPC) (UK)

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. In the UK, the LCP was developed to improve care for dying patients.14 The LCP was developed to take the best of hospice care into hospitals and other settings. It is used to care for patients in the last days or hours of life once it has been confirmed that they are dying. The LCP is designed to enable all healthcare workers to provide optimal care to dying patients, whether they are specialists in palliative care or not, by guiding clinical decision making. The LCP is a legal document which replaces the usual medical record at the end of life, and is structured to facilitate audit and outcome measurement.15 It promotes clear communication around the dying and death of the patient, and it supports psychosocial and spiritual care to the patients and their relatives, for example, by promoting adequate communication and support and giving relatives a brochure for bereavement after the death of the patient.15 The UK and 13 other countries are registered with the LCP Continuous Quality Programme. 16 In Scotland the LCP is applied by 12 of the 13 voluntary hospices; but only a quarter of district nurses reported in 2008 that they are currently using the LCP.17 In NHS Greater Glasgow and Clyde 37% of the GP practices, 33% of the nursing homes and 47% of the wards in the acute operating division are in the process of implementing the LCP.18

1.4 Pharmaceutical care context of palliative care

It is estimated that one in three people in the UK will develop cancer and one in four will die from it.19The survival rate for cancer is increasing with more patients being treated as day-case patients. The length of stay for in patients is also decreasing, therefore it is essential to ensure appropriate care continues in the community setting.20 Hepler and Strand defined pharmaceutical care as improves a patient’s quality of life.21 For pharmaceutical care to be successful, a quality system should be implemented to ensure appropriate patient outcomes. It is important that all pharmacy members of the healthcare team in different settings are included in the delivery of pharmaceutical care.22To ensure continuity of care, pharmaceutical care plans require to be updated when the patient’s needs change. Seamless care helps patients to move across healthcare boundaries without experiencing a gap in the standard of healthcare delivery, but this requires effective communication between primary and secondary care.23 In providing pharmaceutical care, pharmacists co-operate with doctors, patients and/or carers in designing, implementing and monitoring a “pharmaceutical care plan”. The pharmaceutical care provided aims to optimize drug treatment and achieve specified therapeutic outcomes. This has the potential to reduce drug-related problems and improve patient’s quality of life

To support the local delivery of chemotherapy, models of care need to be developed and remote models of care need to be developed and remote patient monitoring performed which is linked to an electronic health record.24 The use of an electronic record would undoubtedly improve seamless care. It is therefore essential that improvements are made in the transfer of pharmaceutical care. Over the past decade, there has been a large increase in the number of patients receiving cancer treatments and symptom relief treatments at day-case chemotherapy clinics25. With the increase in the prescribing of oral chemotherapy and the use of ambulatory intravenous pumps which allow patients to receive continuous chemotherapy at home, there is increasing need for hospital pharmacists to liaise more closely with general practitioners (GPs) and community pharmacists to explain unusual indications for a drug or unconventional dosage regimens. This liaison is needed to avoid incidents reported through the in-house reporting system such as inadvertent continuation of intended short courses of medication, for example, dexamethasone prescribed for three days as an anti-emetic after chemotherapy. There is a need for the required clinical monitoring to be undertaken in primary care to minimise risks associated with these medicines. It is essential that detailed information on monitoring requirements is conveyed from the day-case clinic to the patient’s GP and community pharmacist, so that both are aware of the therapeutic plan for the patient and management of potential toxicities and possible drug interactions.

Methods of transferring care require exploration and hence Julie Fisher et al,in their study examined and designed a documentation system to monitor pharmaceutical care between cycles of chemotherapy for patients who attended an oncology care unit.24 Their study confirmed a recognised need for continuity of pharmaceutical care between hospital and community pharmacists.

The Gold Standards Framework Scotland (GSFS) was introduced in 2003 and is an adapted version of the GSF for implementation within NHS Scotland. The Gold Standards Framework Scotland provides a means of improving the quality of care provided by primary care teams in the final year of a patient’s life. The main differences to the core GSF are : addressing the needs of patients from diagnosis onwards; maintaining a GSF palliative care register, and ; advanced care planning, defined as a process of discussion between an individual and their care providers about individual’s concerns, their preferences for types of care and their understanding of their illness and prognosis.26

Across Scotland, 75% of GP practices are registered as using the GSFS.17 As of 2009, 80%of GP practices in NHS Greater Glasgow and Clyde are signed up for the GSFS.18 The most recent development in 2009 has been the electronic Palliative Care Summary (ePCS). The ePCS allows, with patient or carer consent, the access to daily updated summary information from GP records for Out of Hours services and NHS 24. This facilitates structured and accurate information to be available in hours and out of hours to support palliative care patients and their families. The ePCS includes: prescribed medication, medication diagnosis, patients’ and carers understanding of prognosis, patient wishes about place of care and resuscitation.26, 18.

The UK department of Health has proposed that Primary Care Trusts across England should invest in pharmaceutical care services giving patients access to more help from pharmacists in using their medicines.27 Evaluation of pharmacists’ interventions has shown that they can make a valuable contribution in secondary care settings such as hospices and hospitals.28 Lucas et al found that more than 60% of pharmacists’ interventions in an inpatient palliative care unit could significantly improve patient care.29 The pharmacist advised on the appropriateness of medication regimens, side effects and contraindication of medication and provided drug and prescribing information to patients and staff. Despite being perhaps the most accessible healthcare professional, there is limited research into the possible contribution of community pharmacists to community-based palliative care in the UK. A recent review showed that the delivery of palliative care to patients in the community is far from ideal.30 Inadequacies in knowledge and training of professional currently providing palliative care to patients at home may prevent the patient receiving optimum pain and symptom control.31, 32 Fragmentation and poor organisation of current palliative care services may result in a loss of continuity of care for such patients or hinder the timely availability of appropriate medication.33,34 Poor communication within existing teams and across organizational boundaries also limits the provision of effective palliative care to patients in the community.35,36 If community pharmacists were included in the local network of healthcare professionals, this would benefit all parties, especially patients and carers, and it would help to share the over-increasing work load in palliative care, due in part to an aging population. Needman et al, 37 assessed the effectiveness of community pharmacists’ clinical intervention in supporting palliative care patients in primary care using an independent multi-professional panel review. In their study, they suggested that when trained community pharmacists are included as integral members of the multi-professional team, they can intervene effectively to improve pharmaceutical care for palliative care patients in the community, providing additional support for them to remain at home; because majority of palliative care patients spend most of their last year at home under the care of their GP and the primary care team.38 It is only when the community pharmacist knows and have the details of the patient’s medical condition and prognosis , that she is able to suggest new therapies or to titrate existing ones. Unfortunately in the present UK community pharmaceutical services system, the community pharmacists are unlikely to know the medical diagnosis of the patients or other essential clinical details.39, 40 As a result, community pharmacists in general are unable to make full use of their knowledge and expertise or to anticipate problems and advice on them. The recent NHS pharmacy plan advocates that personal medicine management services should be provided by community pharmacists in the future.27

The study of Needman et al showed that the personal palliative pharmaceutical care services are feasible in everyday practise when community pharmacist is included in the multidisciplinary palliative care team.37

In 2002, the Scottish Government through its publication “The Right Medicine: A

strategy for pharmaceutical care in Scotland”, proposed a better use of pharmacists’ professional competence in planning and delivering services, especially in priority areas such as cancer, heart disease and mental health.41This policy document placed emphasis on the continued development of Pharmaceutical Care Model Schemes including palliative care, initiated in 1999 in collaboration with the Royal Pharmaceutical Society in Scotland. This work has developed and now all NHS Boards have developed Community Pharmacy Palliative Care Networks. Access to specific palliative care medicines within and out with working hours via this network is quality standards in all NHS Board areas.42 Within the NHS Greater Glasgow and Clyde area 71 of the current 312 pharmacies are involved in the Community Pharmacy Palliative Care Network. This network was established in 2001 and is funded by NHS Greater Glasgow and Clyde18, 43, 44. The purpose of the project is to increase awareness of the community pharmacist’s role, their capacity to manage patients requiring cancer and palliative care support, reduce risks and effectively manage anticipatory care needs to minimise out of hours issues. The services of the network pharmacies includes: retailing a stock of more specialized medication which may be required for palliative care; a courier service for transport of urgent prescriptions and medicines, and ; provision of advice and support to other pharmacies, GPs and district nurses.

In 2006, a new community pharmacy contract was agreed with the Scottish Government to modernise community pharmacy practice and to support the delivery of pharmaceutical care. The contract is based on four core services, namely the acute medication service, the minor ailment service, the public health service and chronic medication service (CMS) 45 of which palliative care is one. The Chronic Medication Service (CMS) will also require patients to register with a pharmacy. It will enable a pharmacist to manage a patient’s long-term medication for up to 12 months. Under this service, a patient can have his or her medicines provided, monitored, reviewed and, in some cases, adjusted as part of a shared care agreement between the patient, the GP and the community pharmacist. It is in this service that an emphasis on the systematic approach to pharmaceutical care is particularly apparent; it will incorporate the pharmaceutical care model schemes, serial dispensing and supplementary prescribing.

In October 2008, the Scottish Government published “Living and Dying Well in Scotland. ‘Living and Dying Well’ is the first plan for the development of a single, cohesive and nationwide approach to ensure the consistent, appropriate and equitable delivery of high quality and person centred palliative care based on neither diagnosis nor prognosis but on patient and carer needs. The concepts of assessment and review, planning, coordination and delivery of care, of communication and information sharing and of appropriate education and training are addressed in this Action Plan. The Action Plan states that NHS Boards and Community Health Partnerships (CHPs) should take steps to ensure that patient with palliative care needs are included in a palliative care register and are supported by a multidisciplinary team. The Action Plan also emphasises the importance of proactive care planning and anticipatory prescribing to aid the prevention of unnecessary crisis and unscheduled hospital admissions, particularly out of hours. This also includes the planning for stages of illness trajectories that are likely to produce changing patient needs in the future.

Key to the progress of “Living and Dying Well” is its emphasis on a person centred approach to care and care planning and on the importance of communication, collaboration and continuity of care across all sectors and all stages of the patient journey. In order to fully realise the necessary improvements in palliative and end of life care, NHS Boards should review their projects the “Living and Dying Well” actions and the actions set out in Living and Dying Well: Building on Progress – with particular priority on the following areas.

– Early identification of patients who may need palliative care

– Advance / Anticipatory Care Planning (ACP)

– Palliative and end of life care in acute hospitals

– Electronic Palliative Care Summary (ePCS)

– Do not Attempt Cardiopulmonary Resuscitation (DNACPR)

1.5 Transfer of information in Palliative Care

Access to specialist palliative care services must be more consistent across Scotland, according to a report published by Audit Scotland.17 Audit Scotland investigated the provision of specialist and general palliative care in all NHS board areas. It found a significant variation in the availability of specialist palliative care services and in the ease with which patients can access services.46 Although community pharmacists’ provision of palliative care medicines was not specifically reviewed by the audit, the report notes: “NHS boards reported that provision was well organised through the national community pharmacy scheme”

Many people, who are terminally ill, do prefer to spend their last days in their own homes. It is therefore, essential that these patients have easy access to care and medicines that can help them if their condition were to change rapidly or deteriorate suddenly at night or during the weekend (as is common in terminal illness). However, the provision of out-of-hours specialist palliative care and the availability of palliative care medicines in the community can present major problems.

Communication between professionals and patients/carers is an important aspect of palliative care in any setting. However, effective communication and co-ordination between professionals, especially across organisational boundaries, systems and structures, can play an even more crucial role in ensuring the quality of care and enhancing patient and carer experience. According to “Living and Dying well” in Scotland the aim of communication and co-ordination is

– to ensure that all patients and carers with palliative and end of life care needs are supported to participate fully in developing care plans and making decisions about their care

– to ensure that their needs are communicated clearly across care settings and systems to all professionals involved

– to ensure that the care of all patients and carers with palliative and end of life care needs is co-ordinated effectively between specialists and across care settings and sectors.

The transfer of appropriate information between care settings, including out of hours services and NHS 24, could be improved, and is known to have particular significance for those with palliative and end of life care needs. The Scottish Government is therefore facilitating development of an electronic Palliative Care Summary (ePCS) which is developed from the Gold Standards Framework Scotland Project 47 and is based on the Emergency Care Summary. The ePCS will, with patient and carer consent, allow automatic daily updates of information from GP records to a central store, from where they will available to out of hours services, NHS 24 and Accident and Emergency service. The ePCS is currently being piloted in NHS Grampian, and subject to successful evaluation, will be rolled out nationally from 2009. NHS Quality Improvement Scotland is currently developing National Key Performance Indicators for palliative care which address out of hours issues. The timely sharing of information between primary and secondary care, especially at times of admission and discharge and including transfer between home, care homes and hospitals remains a challenge to be addressed.46 The ePCS now provides a helpful framework for identifying the type of information from assessments and care pans which should be shared. NHS Boards will be expected to ensure, by whatever means are locally available, the availability over 24 hours of such information to all relevant professionals.

1.6 Electronic Palliative Care Summary

The ePCS builds on the Gold Standards Framework Scotland project and the Emergency Care Summary (ECS). The ePCS will, with patient /carer consent, allow automatic daily updates of information from GP records to a central store, from where they are available to Out Of Hours (OOH) services, NHS 24, Acute Receiving Units, Accident Emergency Departments and shortly to the Scottish Ambulance service. The ePCS is now in use in over 23% of practices across 11 Health Board in Scotland.48 The electronic Palliative Care Summary (ePCS) allows practices to: replace the fax form used to send patient information to out of hours services, clearly see essential information on patient with palliative care needs, view or print lists of patients on the practice Palliative Care Register, set review dates to ensure regular review of patients. The information allows practises to build up Anticipatory Care Plans which may include:

– medical diagnoses as agreed between GP and patient

– patient and carer understanding of diagnosis and prognosis

– patient wishes on preferred place of care and resuscitation (DNAR)

– information on medication and equipment left in the patient’s home “just in case”

– current prescribed medication and allergies, as per the Emergency Care Summary (ECS).

ePCS needs to be developed to meet the needs of palliative care patients. This will require electronic transfer of appropriate information across care settings and to be accessible by recognised healthcare workers supporting patient care. This project will review the development to date of relevant electronic transfer systems.

2. Aim and Objectives

Aim

Describe current pharmaceutical care provision and make recommendations for electronic transfer of information through evolving palliative care summaries.

Objectives

2.1 To conduct an extensive literature review to establish current published work as a baseline for describing information summaries to support pharmaceutical care of palliative care patients.

2.2 To describe relevant information summaries in current practice.

2.3 To describe current information transfer across care settings.

2.4 To identify developments in electronic transfer of care summaries and make recommendations on data fields to support information transfer based on evidence.

2.5 To make recommendations to support an electronic palliative care summary (ePCS) for use by pharmacists in different settings providing pharmaceutical care to palliative care patients.

3.Methods

3.1 Description of literature searching

A literature search was conducted in order to identify relevant previous work and experiences in the transfer of information in palliative care to support pharmaceutical care of such patients. The findings are presented in the introduction.

For the outline literature review the biomedical database MEDLINE was accessed and browsed via University of Strathclyde library services. The search was carried out using both MeSH (Medical Subject Headings) vocabulary and plain search terms, either individually or in different combinations. The inclusion criteria comprised articles published between 2010 and around 2000 and publications in English Language.

The following search terms were mainly considered.

Palliative careEnd of life careCancerChronic disease management

Pharmaceutical care provisions

Scotland

United Kingdom

Qualitative research

Out-of-hoursPharmaceutical carePharmaceutical serviceCommunity pharmacyPharmacist

Patient care

Electronic palliative care summaries

In addition, the Google search engine, PubMed, the Google scholar database indexing full texts of scientific literature and the search engine Bing from Microsoft were used and the web pager of several journals like the Pharmaceutical Journal, Palliative Care Journals, Palliative Medicine Journal, British Journal of General Practise, and the British Medical Journal were reviewed applying the same key words. In addition, the websites of a number of professional organisations such as NHS Scotland, NHS 24, and NHS Boards across Scotland, Scottish Government, Community Health and Care Partnerships, Audit Scotland, the Scottish Partnership for Palliative Care and the World Health Organisation were searched for government policy documents relating to palliative care.

3.2 Identification of current practice

Face to face interviews and group meetings and telephone discussions were also deployed in this research work. Group meetings were held with the University team of the Macmillan Pharmacist Facilitator Project, head of pharmacy of NHS 24, a district nurse as well as a palliative care link nurse. The meetings helped as appropriate tools of information due to the fact that they enabled the participants to describe and talk freely about their experiences while retaining a focus on the subjects of interest. A method that facilitates the expression of criticism and the suggestion of different types of solutions is invaluable when the aim is to improve services.49

3.3 Current information transfer to support practice

The head of pharmacy of NHS 24 advised making contact with district nurses or palliative care nurses and the need for them to participate in face to face interviews. The actual recruitment of one district nurse was co-ordinated by a Macmillan Pharmacist Facilitator and the palliative care link nurse agreed to a telephone conversation to capture clinical care issues arising as part of their daily practice.

4.Results

The services provided to patients out-of- hours (OOH) are an essential part of palliative and end of life care, and the issues relating to OOH service provision were of paramount relevance in this research work. The recent changes to the General Medical Services (GMS) contract shifted the responsibility for OOH service provision from GP practices to NHS Boards. This has changed the way in which patients access care outside normal working hours. The establishment of NHS 24 has introduced a new model where 24-hour telephone advice is the single point of access to all OOH services. Patients are now unlikely to receive OOH care from a doctor who knows them and the importance of continuity to palliative care patients means that they are likely to be particularly affected by these changes.50More recently, the establishment of centralized services (NHS Direct in England and Wales, NHS 24 in Scotland) present a new model 24-hour telephone advice that will be the single point of access to all OOH services, even in rural areas. The intention is to benefit patients and carers by offering simple and convenient access to advice and effective triage, so that appropriate care can be delivered quickly and efficiently.51 Responsibility for healthcare is been transferred from GPS to local primary care organisations, which are currently setting up new unscheduled care services. There has been a progressive shift in the locus of care from the home and local general practices to more distant emergency clinics or telephone advice.52 An understanding of the needs and experiences of palliative care patients and their carers is essential to ensure that OOH care is effect as well as efficient.

Alison Worth et al, in their qualitative study of OOH palliative care, explored the experiences and perceptions of OOH care of patients with advanced cancer, and with their informal and professional carers.50 this study made explicit the barriers experienced by palliative care patients and their carers when accessing care. The importance of good anticipatory care particularly provision of information to patients and carers along with regularly updated handover forms sent to OOH services, was identified as key by both patients and professionals. Professionals described the barriers to achieving individualised patient care and the problem posed by competing priorities, but saw potential for improvements through an expansion of OOH resources, particularly nursing and supportive care. Worth et al, compared their study to previous studies which suggested that good anticipatory care, particularly provision of information to patients and carers about sources of help OOH, and what to expect from services, helps maintain care at home and manage patients’ and carers’ expectations of services.53,54According to Worth et al, GPs and district nurses wanted 24-hour access to specialist palliative care advice on symptom management and medication use.55Access to palliative care drugs and advice via a community palliative care pharmacy network is a quality standard in Scotland.42

Many people who are terminally ill want to spend their last days in their homes. For this reason therefore, these patients should have easy access to care and medicines that can help them if their condition change rapidly or deteriorate suddenly at night or during the weekend. However, the provision of out-of-hours specialist palliative care and the availability of palliative care medicines in the community can present major problems. Palliative care medicines are only readily available during normal working hours, Monday to Friday. Feelings of uncertainty and anxiety can be heightened in patients and carers, particularly OOH, if there is no easy access to familiar sources of professional help and advice or to the medicines needed to control symptoms that commonly occur in the terminal phase of a disease.11

The “just-in-case” six-month pilot study which was set up in three areas of the Mount Vernon Cancer Network was aimed to avoid distress caused by inadequate access to medicines OOH by anticipating pharmaceutical needs stemming from new or worsening symptoms; and prescribing medicines to be used on a “just-in-case” basis. The initiative was intended to support the “Gold Standards Framework”, a programme that aims top develop a practice-based system to improve the organisation and quality of care for patients in their last 12 months of life.56 the “just-in-case” box (blue plastic hobby box-27x20x10cm) where medicines were stored at the patient’s home. The prescriptions reflected the individual needs of each parient and were written up in the patient’s notes and on an administration sheet used only for anticipatory or when required medicines. An approved list of medicines for symptom control in patients in the terminal phase of an illness was made available through the Liverpool Care Pathway for the dying patient15, 57 and this was adopted for the pilot. As a result, the medicines usually supplied on a “just-in-case” basis were diamorphine (for pain), midazolam (for agitation), cyclizine, haloperidol or levomepromazine (for nausea or vomiting), glycopyrronium or hyoscine hydrobromide (for respiratory secretions).

Information transfer in palliative care is currently underdeveloped because most of the information is within the decision of the GP. Presently NHS 24 does not have access to patients’ medical records. Anytime a call is made to NHS 24, a record is made, a previous contact is seen and all reports are documented as well as the resources and advices used in the past. However, from May 2007, all NHS 24 centres are now able to access a patient’s Emergency Care Summary (ECS) provided patient’s consent is first obtained.

The Emergency Care Summary (ECS) is a relatively new system which allows information on a patient’s medication and allergies to be automatically extracted from their GPs records. The security around accessing ECS is very strict and any time an access is made, it is logged so as to know who has been seeing it and this is especially doctors. The NHS 24 has access to ePCS but there is nothing on the ePCS that mentions medicines and that element of pharmaceutical care is missing in the ePCS.

Legislation was introduced throughout the UK in 2000, which provided the framework for the supply and administration of medicines without the need for an individual prescription.

This framework was Patient Group Directions (PGDs).

According to NHS Education for Scotland (NES), a Patient Group Direction (PGD) is a written instruction for the sale, supply and /or administration of named medicines in an identified clinical situation.58 It applies to groups of patients who may not be individually identified before presenting for treatment.

Before now, out-of-hours GP care in England, Denmark and the Netherlands has been reorganised and the Netherlands has been reorganised and is now provided by large scale GP co-operatives. Adequate transfer of information is necessary in order to assure continuity of care, which is of major importance in palliative care. Schweitzer et al, conducted a study to assess and investigate the availability, content and effect of information transferred to the GP co-operatives.59 According to their study, GPs in the UK were satisfied with the palliative care provided by their out-of-hours co-operatives, but satisfaction was less for inner city GPs who had concerns about the continuity of care.60 District nurses reported less satisfaction, especially with the quality of the advice, the reluctance to visit, and difficulties in obtaining medication.61 In their study , the total number of palliative care phone calls was 0.75% of all calls to the GP co-operative. Information was transferred and the content consisted mainly of clinical data. It was also found that half of the calls regarding palliative care resulted in a home visit by the locum, and that medication was prescribed in 57%of all palliative care calls. According to this study, a report from the UK stated that a lack of information can lead to problems in symptom control and an increase in unnecessary hospital admissions.62 This study recommended that GP co-operatives needed to develop and implement an effective system of patient information management. The potentials for improvement in the end-of-life care that is provided by the GP co-operatives was a factor of information transfer especially if an electronic patient file is accessible during the out-of-hours period, and this should contain information that is of relevance to locums.

The two nurses who took part in the interviews suggested that the service provided for palliative care patients has improved a great deal over the past few years especially with the introduction of the Gold Standards Framework Scotland. An integral part of this improvement was said to be the anticipation of patients’ possible future needs [by the development of Anticipatory Care Plan (ACP)], so that the essential equipment and drugs are either already in place when they become necessary or else can be obtained without delay. This act was identified as reducing the need to call the local out-of-hours GP services over the weekend or in the evenings. The district nurse explained that patients and their carers/family were given details of how to contact the evening or night nursing service who was on call and when one action/plan was carried out the next nurse who is giving care to the patient is able to see what the previous nurse had done. This was done with the use of a “mobile computer”. The palliative care link nurse explained that the ePCS was not accessible by nurses yet but this is being looked into by GPs but nurses who needed access were allowed by their GPs.

During out-of-hours, GP practices cannot provide essential services and general management to patients who are terminally ill. Following an independent review of GP out-of-hours services, Primary Care Trusts (PCTs) are also responsible for developing a more integrated out-of-hours system. (Carson Review). The Carson review envisaged that the needs of palliative care patients will be identified in advance noted on the NHS Direct database and passed directly without triage to the service they needed.63This followed from recommendations that transfer of information between GPs and their out-of-hours provider is essential to ensure continuity of care 62, thus forming one of the current GP co-operative accreditation standards.64 Burt J et al, conducted an audit across four co-operatives to assess progress of continuity of care within primary palliative care in England.61Across these four co-operatives, there were 279 palliative care-related calls (2.1% of all calls), form 185 patients during the audit month. The co-operatives held handover information for between 1 (12%) and 13 (32.5%) of these patients. Co-operative doctors had information about previous co-operative contacts for 7.5-58.1% of repeat calls. Three co-operatives faxed details of every palliative care contact to the patient’s GP the following morning, one did so for only 50% of calls. This system of alerting the co-operatives to the needs of palliative care patients was under-utilized. Even within the most frequently used systems, the diagnosis, prognosis and care preferences of two thirds of patients with palliative care were not made known to the co-operatives.

5. Discussion

Information that encourages appropriate use of out-of-hours services needs to be made accessible for all patients and carers. Primary care professionals and community palliative care specialists share responsibility for advising patients and carers on how to seek help out-of-hours. Practices and primary care organisations need to develop and audit effective systems of patient information management and transfer. These could be included in quality standards. Reviewing the way calls are handled by NHS 24, in addition to their factual content, offers opportunities for communication difficulties to be highlighted and included in staff development. Effective out-of-hours community palliative care requires an integrated, multidisciplinary service that is able to respond to planned and acute needs. Continuity of care may be personal, informational or managerial, the latter implying a consistent and coherent approach responsive to the patient’s changing needs.63 In the context of current primary care provision, personal continuity of care is increasingly unlikely to be provided out-of-hours, but informational and management continuity, supplemented by good communication, may suffice.

There is a relative lack of communication and joint working between all health care professionals involved in the care of patients with palliative care needs and this is a major issue affecting the effective delivery of services. Since the district nurses are the professional seeing the patients more regularly, they are an important resource and a vital link person and pharmacists could consult them for information about a patient’s clinical condition or for clarification of problems caused by incorrect or incomplete prescriptions. As at January 2011, the ePCS is now in use in over 32% of practices across 11 Health Boards in Scotland. All three GP IT systems have software for recording ePCS information which is updated automatically to ECS when any changes are made. ePCS is the available to all out-of-hours-and unscheduled care users who already have access to ECS. The information in the ePCS is recorded in the GP system to form an Anticipatory Care Plan which will be available out-of-hours and includes medical diagnoses (as agreed between the GP and patient), patients and carers’ understanding of diagnosis and prognosis, patient wishes {preferred place of care and resuscitation (DNACPR)}, information on medication/equipment left in patients’ home “Just in Case and prescribed medication (this includes all repeat and last 30 days acute and allergies as per ECS. Though the patients’ medicines are not described in detail, that element of pharmaceutical care is not present on this current ePCS. (Appendix 1). The reason for this may be because of a skills gap for instance, independent prescribers might be few in this clinical area. The way pharmacists can adjust medicines as part of an agreement in the delivery of care to palliative care patients should be included in the ePCS.

Boards across Scotland are aligning the rollout of ePCS with their plans for moving GP IT systems from GPASS to either InPs Vision o EMIS and local champions in Greater Glasgow and Clyde and Dumfries and Galloway have encouraged uptake of ePCS. Work is at early stages in Ayrshire & Aran, Fife, Orkney and Western Isles. Shetland is planning to start the rollout shortly. Grampian has completed connection for all EMIS and Vision practices and further rollouts will start shortly. Lothian has been using ePCS for a year, and is now planning how to maintain usage and encourage the remaining practices. Lanarkshire have a good uptake in Gpass practices and are awaiting the completion of the Gpass to InPs Vision migrations before wider rollout is commenced. Scottish Ambulance Services (SAS) is now piloting the use of ECS and ePCS in Lothian.48

According to Burt et al, co-operative doctors were required to provide care in a range of complex and time-consuming cases, including during the last days and hours of a patient’s life, with little or no information. Continuity of care within co-operatives was frequently threatened by a lack of information about previous contacts to the service by a patient.61 Within the present and new integrated out-of-hours systems, the effective transfer of patient information between all providers will be critical if palliative care patients and other vulnerable groups are to receive the care they need, especially where GPs opt out of providing out-of-hours care. Electronic patient records may provide a solution, although concise, up-to-date information will be needed and as services move to a more integrated approach (ePCS), a careful scrutiny of information transfer systems and encouragement of providers such as GPs and district nurses to update information, may help to ensure better continuity of care.

The current ePCS (see Appendix I) describes the patient’s medical conditions (current drugs and doses, and additional drugs available at home); the current care arrangements (syringe driver at home); the extent to which patients and carers understands the present condition of the patient and the advice for out-of-hours care. According to “Living and Dying Well 46, there is a need for communication and co-ordination between all professional who are involved in providing care to palliative care patients. This will help ensure that all patients and carers with palliative and end of life care needs are supported to participate fully in developing care plans and making decisions about their care. To ensure that their needs are communicated clearly across care settings and systems to all professional involved. To also ensure that the care of all patients and carers with palliative and end of life care needs is co-ordinated effectively between specialities and across care settings and sectors. The introduction of more joint out-patient clinics for example the joint respiratory/palliative care out-patient clinic at Victoria Infirmary in Glasgow should be encouraged.

6. Conclusion

Although the electronic Palliative Care summary (ePCS) is being rolled out in almost all Health Boards across Scotland, there are still some areas of care delivery that needs to be improved in palliative care especially during out-of-hours. A model needs to be fashioned out to enhance what the next step in the delivery of palliative care should be. If anything is done by one member of the palliative care team, other members need to know within the shortest time possible. The pharmacist who is an important member of the team, at the moment do not have access to the ePCS, this area needs to addressed. There is also need to use the new and emerging technology in the delivery of unscheduled healthcare, for instance strategic frontline application, which means upgrading the current IT and telephoning capability as well the potential for video conferencing in pharmacies. In current practice special notes (a flag facility that can be attached to a patient’s CHI number by GPs) used by GPs can be replaced by special texts in palliative care practice.

Calls to out-of-hours through NHS 24 can also be by video calls and texts as this enhances telephone assessments especially in palliative care. Development of specialized care plans should also be encouraged. There should be equitable access to a range of health care professionals and support staff across the UK and this may well demand additional resources, particularly for district nurses. Partnership working with non-statutory palliative care providers should also be enhanced. Specialist palliative care telephone advice to unscheduled care services, including access to a consultant in palliative medicine, may need to be delivered through extended rotas in areas where there is a shortage of specialists. The ePCS should be able to provide more pharmaceutical care provision to patients.

Introduction

A Project is the combination of organizational resources pulled together to create something that did not previously exist and that will provide a performance capability in the design and execution of organizational strategies (Cleland and Ireland, 2006). Projects have a distinct life cycle, starting with an idea and progressing through design, engineering and manufacturing or construction through use by a project owner. For a project to be successful there are main things which are to be considered always, like the cost of the whole project, time that it’s going to take for it to be complete, the technical performance capability that it’s going to provide and be able to match the results with the design and execution of organizational strategies. This whole process in the other name it’s called Project Management.

Project management is an important management tool to implement strategy and achieve an organization’s strategic goals. Organizations are using projects to adapt to changes in the competitive environment including increasing cost pressures, scarce available resources, global competition, new technologies and a race to get products to customers first (Hyvari, 2006). Projects deliver the most benefit when they are directly linked to corporate strategy (Crawford, 2006, Srivannaboon, 2006).

Also, Project Management is a continuing process of controlling the development of a project from initial planning, to monitoring progress and finally to seeing the successful completion of the project. Every program, project, or product has certain phases of development known as life cycle phases. A clear understanding of these phases permits managers and executives to better control resources to achieve organizational goals (Kerzner, 2003). As a result, the project manager must learn to deal with a wide range of problems and opportunities, each in a different stage of evolution and each having different relationships with the evolving project (Cleland and Ireland, 2002).

In this assignment, I’m going to discuss all the activities that are required and analyse some of the techniques, methods and tools used on the project life cycle. Also, I will discuss the skills and competences that project managers’ needs to possess. At the end, I will talk about the roles played by the stakeholders and the contribution of the computer packages towards the successful running of a major project.

a)

The Project Life Cycle refers to a logical sequence of activities to accomplish the project’s goals or objectives. Regardless of scope or complexity, any project goes through a series of stages during its life. There is first an Initiation or Birth phase, in which the outputs and critical success factors are defined, followed by a Planning phase, characterized by breaking down the project into smaller parts/tasks, an Execution phase, in which the project plan is executed, and lastly a Closure or Exit phase, that marks the completion of the project. Project activities must be grouped into phases because by doing so, the project manager and the core team can efficiently plan and organize resources for each activity, and also objectively measure achievement of goals and justify their decisions to move ahead, correct, or terminate. It is of great importance to organize project phases into industry-specific project cycles. WhyNot only because each industry sector involves specific requirements, tasks, and procedures when it comes to projects, but also because different industry sectors have different needs for life cycle management methodology. And paying close attention to such details is the difference between doing things well and excelling as project managers.

Diverse project management tools and methodologies prevail in the different project cycle phases. Let’s take a closer look at what’s important in each one of these stages:

1) Initiation

In this first stage, the scope of the project is defined along with the approach to be taken to deliver the desired outputs. The project manager is appointed and in turn, he selects the team members based on their skills and experience. The most common tools or methodologies used in the initiation stage are Project Charter, Business Plan, Project Framework (or Overview), Business Case Justification, and Milestones Reviews.

2) Planning

The second phase should include a detailed identification and assignment of each task until the end of the project. It should also include a risk analysis and a definition of a criteria for the successful completion of each deliverable. The governance process is defined, stake holders identified and reporting frequency and channels agreed. The most common tools or methodologies used in the planning stage are Business Plan and Milestones Reviews.

3) Execution and controlling

The most important issue in this phase is to ensure project activities are properly executed and controlled. During the execution phase, the planned solution is implemented to solve the problem specified in the project’s requirements. In product and system development, a design resulting in a specific set of product requirements is created. This convergence is measured by prototypes, testing, and reviews. As the execution phase progresses, groups across the organization become more deeply involved in planning for the final testing, production, and support. The most common tools or methodologies used in the execution phase are an update of Risk Analysis and Score Cards, in addition to Business Plan and Milestones Reviews.

4) Closure

In this last stage, the project manager must ensure that the project is brought to its proper completion. The closure phase is characterized by a written formal project review report containing the following components: a formal acceptance of the final product by the client, Weighted Critical Measurements (matching the initial requirements specified by the client with the final delivered product), rewarding the team, a list of lessons learned, releasing project resources, and a formal project closure notification to higher management. No special tool or methodology is needed during the closure phase.

Reference List

Kerzner, H. (2003). Project management: a systems approach to planning, scheduling, and controlling (8th ed.). New Jersey: John wiley & Sons Inc.

Cleland, D.I, Ireland, L.R. (2006). Project Management: Strategic Design and Implementation (5th ed.). New York: McGraw-Hill, pp. 26

Cleland, D.I, Ireland, L.R. (2002). Project Management: Strategic Design and Implementation (4th ed.). New York: McGraw-Hill, pp. 32

Crawford, L., Hobbs, B. & Turner, J.R. (2006), Aligning capability with strategy: Categorizing projects to do the right projects and to do them right, Project Management Journal; Jun. 37, 2; ABI/INFORM Global, pp.38-50

Hyvari, I. (2006), Project management effectiveness in project oriented business organisations, International Journal of Project Management, 24 pp. 216-225

Srivannaboon, S. (2006), Linking project management with business strategy, Project Management Journal, Dec; 37, 5; ABI/Inform Global, pp.88-96

Introduction

In the play Wit written by Margaret Edson, the main character, Vivian Bearing, decides to donate her body to medicine to help better understand the ruthless disease of cancer and death itself. While many seem to believe that the theme of the play deals with the relationship between the doctor and patient, I felt the sole purpose of Wit was purely educational and depicted the beginnings of technological and medicinal feat. Dr. Bearing undergoes full dosage of painstaking treatments in chemotherapy against her stage-four metastatic ovarian cancer and is ultimately used as a specimen for the greater good of humanity. When Dr. Bearing had been notified that her cancer had become in an advanced stage, this event in itself, justifies that a person’s life can change drastically in a matter of seconds. Dr. Bearing’s infatuation with John Donne also supported the theme of Wit in which both had a deep urge to comprehend death and cancer to a whole greater level. According to, “The Amazing Grace of Margaret Edson’s Wit” by John Heilpern, while Vivian Bearing was enraptured with John Donne’s poems, Donne’s infatuation dealt with “the fatal mystery of replicating cancer cells.” In which John Donne explains, “immortality in culture.” The desire of wanting to know more about the development of cancer is evident in both characters. The reputation and facade Dr. Bearing had gotten was an arrogant and uptight professor who had nothing to give, but in reality her agreement to undergo the treatments and staying “tough” throughout the entire process gave science and medicine a huge leeway.

Katherine Margaret Rossiter, the author of “Undoing Wit: A Critical Exploration of Performance and Medical Education in the Knowledge Economy” states that Margaret Edson’s play has been widely used in medical education. (Paragraph 3) The advancements made in the medical field are still fairly new and young and are still currently continuing to advance at a very rapid rate. Dr. Bearing is held accountable to be a heroic character in Wit because she had led a life in which she wanted to and then undoubtedly is sacrificing her deteriorating body to science. According to the article, there has been a movement in the applied health research where the medical field is starting to use performance and stories as a tool for knowledge translation. Rossiter goes on to say, “researchers have struggled to find new and engaging ways to communicate complex research findings regarding the human condition.” (Paragraph 1) Essentially, the act of performing out these medical related problems helps viewers to understand and comprehend the realistically portrayal of everyday hospital life. Pamela Renner, the author of “Science and Sensibility” also states, “Wit sticks closer to realism, and closer to home. The performance is a landmine: explosive, unsentimental and wise to the core.” (Paragraph 4) The reaction retrieved from viewers depicts how a real life performance done by actors has a greater effect on people’s emotions and thought process.

After agreeing to Dr. Kelekian’s offer of undergoing full dosage of chemotherapy Vivian Bearing admits that there is going to be a “test.” (Edson, 13). The “test” refers to a gamble with life and death, in which Dr. Bearing is now in limbo of either surviving the tiring effects chemotherapy has on a human body or falling into the cold hands of death. Dr. Bearing goes on to state John Donne, the poet in which she deeply holds a passion for in analyzing his work, and how Donne explored the mortality in greater depth than any other works in the English language. The poem that is analyzed thoroughly in this play is “Death Be Not Proud” by John Donne. The line, “And death shall be no more, Death thou shalt die.,” becomes notable once Vivian Bearing realizes that, “death is no longer something to act out on a stage, with exclamation points. It’s a comma, a pause.” (14). The idea of death and that the only thing separating every living creature a step away from death is the fact that, it is merely nothing but a breath, this in turn heightens the sentimental atmosphere.

The realization of how fragile the human body can be is the main foundation and reason that drives scientists to get a better understanding about the diseases that can harm us. The studies and research scientists have and are still accomplishing are results from experiments and observations made on test subjects. Elizabeth Klaver, the writer of the article, “A Mind-Body-Flesh Problem: The Case of Margaret Edson’s Wit” claims, “For medical science, that object is, not surprisingly, the human body, which offers itself as the field of research, the specimen under observation, the flesh subjected to ‘wit.’” (559) The role of Vivian Bearing was ultimately a role in which it helped the medical field a great step towards improvement and greater research. It is seen throughout the entire play that humanity is still by her side every minute of the way. Dr. Bearing’s nurse, Susie, is the face of humanity whereas Jason, Vivian’s Oncologist, and Dr. Kelekian are the faces of medical science and the greater future. There are breakthroughs every day in science and in the medical field. Although Margaret Edson based her play from her own personal experiences, such as working as an inpatient floor captain in the AIDS and cancer wards at the National Institute of Health’s research hospital located in Washington, D.C., the happenings in a hospital room is something one can always find themselves relating to it.

According to the article, “Trends in United States Ovarian Cancer Mortality, 1979-1995” by Kathleen A. Oriel, Ellen M. Hartenbach, and Patrick L. Remington, studies show that, “Better understanding of how modifiable risk factors and treatment methods affect ovarian cancer mortality trends is needed.” (Paragraph 3) Essentially, research on the treatment towards ovarian cancer and the understanding of the cancer were still being tested and needed to be experimented upon even more. The playwright Wit was publicly published around the year 1995, and the article displays the trends that were obtained during the periods of 1980-1995 and the impact on the deaths caused by ovarian cancer. The article also claims, “Ovarian cancer is the fourth leading cause of cancer death among women, with one in 70 women developing this disease during her lifetime.” (Paragraph 4) Ovarian cancer, like AIDS, was a new strain of disease that was discovered and a range of experiments on how to cure or decrease the cancer cells had to be performed. As technology and studies on ovarian cancer increased, the survival rate had also improved greatly over time. The treatments dealt with more aggressive surgical management and effective chemotherapy. This technique of treatment is seen in the play itself and is performed on Dr. Bearing.

Many people feel sympathetic for Dr. Bearing due to the fact that the audience intakes the feeling that Dr. Bearing’s doctors are indifferent and apathetic towards her as she starts to show the side effects of chemotherapy, but I tend to disagree. Once Dr. Bearing had been diagnosed with ovarian cancer, she inevitably fell into the category of research and science. The play in fact depicts a nice balance between humanity and medicine, and the beginnings of human research on cancer and other harmful diseases. As Elizabeth Klever states, “The play demonstrates a contradictory moment in the history of Western culture: two humanist fields dedicated to a tradition of social and individual improvement – medicine and literature.” Jason and Dr. Kelekian are set examples of medicine and science. They are driven to know more about the human body and how it functions. It is evident that once Jason Posner and Dr. Bearing meet, he is overall fascinated about Dr. Bearing’s situation and status. “(He feels the mass and does a double take.) Jesus! (Tense silence. He is amazed and fascinated.)” (Edson, 27) Once he is aware of how large Vivian Bearing’s cancer has gotten to, he is shocked and taken aback. These are the exact situations that scientists and doctors thrive on about the human form and wanting to discover the cures against the harmful diseases that result in a frail and weak body. Klever also claims, “Still today, the collective brainpower of researchers like Dr. Kelekian and Jason focuses all its resources on vanquishing the mysteries of a completely separable and empirical “specimen,” the body – all for a cure” (667). If it had not been for Vivian Bearing to be experimented on, it may have been the next person who developed ovarian cancer to be tested on.

Sayantani DasGupta, the writer of “Reading Bodies, Writing Bodies: Self-Reflection and Cultural Criticism in a Narrative Medicine Curriculum” states, “As reading women’s illness narratives allowed students to hear the voices of patients, writing and sharing their personal illness narratives allowed them to hear their own voices.” (Paragraph 26) This technique is seen in the play Wit, for the narrator, Vivian Bearing, expresses her thoughts and opinions through text and literature, as well as acting. The play is told in the perspective of a dying patient, rather than the doctor or nurse; this puts a more dramatic effect on the audience, displaying how strong Dr. Bearing is mentally.

Reference

Rossiter, Katherine Margaret. Undoing Wit: A Critical Exploration of Performance and Medical

Education in the Knowledge Economy.PsycINFO. Web. 26 Apr. 2011.

DasGupta, Sayantani. Reading Bodies, Writing Bodies: Self-Reflection and Cultural Criticism in

a Narrative Medicine Curriculum. 22 Vol. Johns Hopkins University Press, 2003.

ProQuest Central. Web. 27 Apr. 2011.

Edson, Margaret. Wit. Harper & Row, Inc. 1942. Playwright. 20 Apr. 2011. Text.

Jones, Therese, and Delese Wear. THE MEDICAL HUMANITIES: Introduction. 50 Vol. Johns

Hopkins University Press, 2007. ProQuest Central. Web. 27 Apr. 2011.

Klaver, Elizabeth. “A Mind-Body-Flesh Problem: The Case of Margaret Edson’s Wit.”

Contemporary Literature. University of Wisconsin Press. (559-683). ENWR-106-04. Blackboard. 21

Apr 2011. PDF File.

Oriel, Kathleen A., Ellen M. Hartenbach, and Patrick L. Remington. “Trends in United States

Ovarian Cancer Mortality, 1979-1995 : Obstetrics & Gynecology.” Obstetrics &

Gynecology. © 1999 The American College of Obstetricians and Gynecologists, Jan.

1999. Web. 27 Apr. 2011.

Renner, Pamela. Science and Sensibility. 16 Vol. Theatre Communications Group, Inc, 1999.

ProQuest Central. Web. 26 Apr. 2011.

Heilpern, John. “The Amazing Grace of Margaret Edson’s Wit.” Observer.com – New York

Politics, Media News, Real Estate, Fashion, Gossip, Movies, Books, Theater, and the Arts

The New York Observer. 31 Jan. 1999. ENWR-106-04. Blackboard. 26 Apr. 2011.

Microsoft Word File.

1. Introduction

The following essay considers the role that unconscious factors play in organisational life, and looks at the extent to which awareness of these factors amongst workers can improve outcomes for users. The idea is considered both in relation to appropriate literature and also in relation to my own experience of a social work organisation, the placement I experienced in a children’s home. The ways in which social work practice can be oppressive and anti-oppressive, and the impact of both of these for the user, are also explored. My interest in this area has been informed by my experience in a care home for children (Adeza) as a student social worker. I worked with a wide range of client groups including children (and their families) under stress, children (and their families with mental health problems, children at risk and children with physical and mental disabilities. I had a wide range of duties including administrative functions, advising clients and supporting children in a variety of ways. I became aware of the ways in which unconscious attitudes can impact upon the way clients and other staff are treated through a phenomenon I later learned was called projection, that is, the psychological mechanism whereby worries and fears about oneself are seen as present in other people, and demonised. For example, some clients had internalised a set of notions about being inadequate parents, which were then projected onto staff at the home, in a variety of ways.

2. The Notion of the Unconscious

Understanding human needs, wants and motivations is a central part not only of organizational theory but also of human psychology generally. Various theories have been proposed to explain the variety of behaviours which characterise human beings, for example behaviourism, which reduces the role of the ‘mental’ and looks at human actions in terms of stimulus and response (Baran and Davis 2011), and Weber’s idea of work as salvation (Nelson and Quick 2010). However, the notion of the unconscious has been widely influential, and derives from work by Freud in the late 19th and early 20th Century.The idea is situated in the wider set of notions developed by Freud called psychoanalysis.Central to Freud’s idea is the notion that “powerful unconscious drives, mostly sexual and aggressive… motivate human behaviour and put people in conflict with social reality” (Saiyadain 2003, p. 32).For Freud, the unconscious is that of which we are unaware, but which can manifest itself through thoughts and behaviours. He separated out three levels of consciousness:

The conscious (everything one is aware of)
The preconscious (things one is not aware of, but which could be brought to consciousness through effort of will)
The unconscious (that of which one is unaware, and which one is normally powerless to bring to conscious awareness)

The unconscious includes desires, buried memories, desires and needs. Individuals can be motivated by unconscious forces, which make themselves manifest through behaviour, thoughts, feelings and words. Freud believed therapeutic work could be done by uncovering these unconscious forces and making the individual aware of their deeper motivations through a process of psychoanalysis (McKenna 2000).

Freud suggested a number of ways in which the contents of the unconscious work to influence human behaviour. These include regression, repression, sublimation and projection. Regression is the phenomenon whereby people return to earlier behaviour patterns (for example a stutter), repression means the ways in which unpleasant emotions are blocked from conscious awareness, sublimation denotes the way in which impulses (perhaps aggressive) which are unacceptable to the conscious mind are channelled into another activity, for example devotion to work or sport, while projection means the mechanism whereby thoughts or feelings which are not acceptable to the conscious mind are attributed to someone else (finding them lazy, for example) (Saiyadain 2003).

Intuitively, and based on my experience in my placement, I feel that there is evidence for the existence of the unconscious. For example, I have seen adolescent children regress to an earlier stage, displaying bed wetting and thumb sucking for example, particularly at times of great stress. However, Freud’s ideas have been subject to an intense critique, particularly that there is a lack of empirical evidence for them (Hersen and Thomas 2006). Additionally, it has been pointed out that the idea of the unconscious lacks predictive power: although it can function as a good explanation of behaviour, it cannot indicate how people will behave in the future (Abbott 2001). I can see that these are valid criticisms: however, as the next sections show, I feel the concept of the unconscious and its mechanisms invaluable in understanding people better, which I feel is a necessary part of delivering the person-centred care that is a key part of social care in the 21st Century (Joseph Rowntree Foundation 2011).

3. The Unconscious and Organisational Life

As well as being widely influential (though much debated) in psychology generally, the concept of the unconscious and its mechanisms has been incorporated into theories of organisational life. The key element to the idea of the unconscious is the notion that “much of the rational and taken-for-granted reality of everyday life expresses preoccupations and concerns that lie beneath the reality of conscious awareness” (Morgan 1998, p. 186). It follows that organisational theories need to take account of the hidden dynamics which influence the workplace. In addition, it has been suggested that theorists of organisational behaviour have been influenced by unconscious forces such as repression. Morgan 1998, for example, suggests that Taylor’s model of ‘scientific’ and rational management might have been rooted in his puritan background with strong routines and work ethic. Morgan also suggests that the predominant bureaucracy of modern work places might be a function of repression. Worker’s reactions to these types of workplace will depend upon their own mechanisms of regression. In other workplaces, organisational culture can often by dominated by self-centred attempts at wrestling control from others, or the playing out of “a phallic-narcissistic ethos” (Morgan 1998, p. 192) within the workplace. Often, the workplace might reproduce the traditional patriarchal family, with a dominant style associated with ‘male’ qualities of aggression, ambition and rigid rules.

One unconscious mechanism which I was particularly aware of in my placement was projection.In this, workers deal with internal turmoil by attributing the key elements of what is bothering them to someone else rather than themselves. For example, in an organisation, poor results might be blamed by one group (managers) on ground-level staff, and vice-versa (Rashid 1983). Projection has been succinctly defined as the “attribution of one’s own attitudes and beliefs onto others” (Borkowski 2009, p. 56). In order to avoid feelings of guilt or excess anxiety, workers might see their co-workers as possessing the qualities they most dislike in themselves (Borkowski 2009). While it allows the person doing the projecting to protect their self-esteem, the mechanism whereby co-workers, for example, are blamed for putting a person in a bad mood, are damaging to organisational efficiency (Borkowski 2009). It can lead to stereotyping and, through this, to oppressive working methods. stereotyping is a way of organising experience by applying common traits to certain groups of people (the elderly, ethnic minorities, children). While it allows abstract thought to take place more easily, it can lead to the association of negative traits with particular groups. Projection seems to be at work in stereotyping, whereby a group is seen to possess negative characteristics not held by the person ascribing the characteristics. It has been shown that these mechanisms can lead to worse health and social care for certain groups seen as ‘the other’ (Borkowski 2009). One example is that people working with abused children can be marginalised and rendered invisible, as society as a whole does not want to admit that such abuse exists. Nurses are also often forced to bear the brunt of negative projections from service users and other professionals. In addition, social work in general often suffers, as its existence underlines the presence of vulnerable and needy people, mortality and other key issues. These all evoke deep and complex feelings in others, and workers in these professions often bear the weight of others negative expectations, “issues of dependency, aggression and sexuality” Yelloly and Henkel 1995, p. 195).

Within social work, it has been acknowledged that certain forms of practice can be oppressive, particularly to service users but also to other workers. Anti-oppressive practice works to overturn ways of working which marginalise, scapegoat and downplay the people who they work for, both on a personal and micro- level, and at a wider social level. While anti-oppressive practice covers a wide range of activities, becoming aware of the extent to which people are marginalised through unconscious mechanisms such as projection is one key part (Balloch and Hill 2007). Becoming aware of the extent to which negative characteristics are projected onto others, either individuals or groups, is a central step in moving away from oppression. Today, immigrant groups can find themselves scapegoated for the wider problems of society, for example, both by individuals and by political groups (Shulman 2008). Anti oppressive practice offers a way for projection, stereotyping and discrimination to be combated in the workplace, through an attitude of criticality and reflection upon situations in the workplace. The process of uncovering oppression can be likened to that of becoming aware of unconscious processes, as well as uncovering motivations which derive from unexamined unconscious attitudes and mechanisms (Heenan 2011).

4. Understanding the Unconscious and Improved User Outcomes

The ways in which the unconscious operates in the organisational context, the negative impact it can have, and the opportunities it presents for ultimately improving user outcomes is illustrated by my experience working in a children’s home.I have concentrated above on the phenomenon of projection, because this was the unconscious mechanism which most appeared to be in existence during my placement. One child with whom I worked, supporting to live independently after care, would frequently express the opinion that the women staff with whom she came into contact were ‘useless’, were over-emotional, and were not as effective as male staff. I used to find this frustrating, particularly as she was female herself, until I put her case into the context of her background. One of a family of girls, with whom her mother was unable to cope, she had internalised negative feelings about women, developed a androgenous, tomboy-ish appearance herself, and projected doubts and fears about herself onto female staff.

There are also discusses about two related unconscious mechanisms (first identified by Melanie Klein), splitting and projective identification, both of which I experienced during my placement.Splitting often occurs in groups, and refers to the process whereby a situation is polarised and seen as ‘black’ and ‘white’, that is, with ‘good’ and ‘bad’ elements. It happens when people are unable to tolerate ambiguity (Zachar 2000). I saw this in group discussions between staff, when one manager who took a fairly strict line to discipline and adherence to regulations was demonised by staff informally after meetings. I felt (perhaps because I was an outsider) that although she might have expressed her ideas better, there was a great deal of sound advice in what she said. However, others seemed unable to see this, preferring to make her a ‘scapegoat’ for everything they disliked about the experience of working in the care home. I also saw this situation improve when a higher manager called a meeting in which we discussed communication styles used within the home.I also saw projective identification, where people unconsciously identify with another person or group, with one staff member, who seemed to project feelings of her own vulnerability (she had just gone through a difficult divorce) onto the female white children in our care. Her attitude towards this gender / ethnic group was markedly different, she would spend extra time with them, and buy small presents. I was present when this was noted by another staff member, who carefully suggested her experience might be leading to her favouritism. She took this suggestion very well, and her behaviour, I noticed, became fairer afterwards.

5. Conclusion

There are some problems with the notion of the unconscious, particularly its lack of predictive power and lack of empirical evidence. However, in terms of my placement in a children’s care home, I have found it a useful way of understanding why people – both staff and clients – behave in the way they do. It also seems to offer a useful tool for moving towards an anti-oppressive practice. In my experience, if people are made aware of the ways in which unconscious mechanisms operate, they are better able to see their oppressive actions, better able to understand why they are acting as they do, and as a consequence able to change the way they behave in a way which is beneficial to clients.

6. References

Abbott, T (2001) Social and personality development Routledge, UK

Balloch, S and Hill, M J (2007) Care, community and citizenship: research and practice in a changing policy context, The Policy Press, Bristol.

Baran, S J and Davis, D K (2011) Mass Communication Theory: Foundations, Ferment, and Future (6th edn.), Cengage Learning, Belmont, CA

Borkowski, N (2009) Organizational behavior, theory, and design in health care, Jones & Bartlett Learning, USA

Foster, A and Roberts, V Z (1998) Managing mental health in the community: chaos and containment, Routledge, UK

Heenan, D (2011) Social Work in Northern Ireland: Conflict and Change, The Policy Press, Bristol.

Joseph Rowntree Foundation (2011) ‘Transforming social care: sustaining person-centred support’, Joseph Rowntree Foundation, UK

McKenna, E F (2000) Business psychology and organisational behaviour (3rd edn.), Psychology Press, UK

Morgan, G (1998) Images of organization, Berrett-Koehler Publishers, California CA.

Nelson, D L and Campbell, J (2010) Organizational Behavior: Science, the Real World, and You (7th edn.), Cengage Learning, Belmont, CA.

Rashid, S A (1983) Organizational Behaviour, Taylor & Francis, UK

Saiyadain, M S (2003) Organisational Behaviour,m Tata McGraw-Hill Education, India.

Shulman, L (2008) The Skills of Helping Individuals, Families, Groups, and Communities (6th edn.), Cengage Learning, Belmont, CA.

Thomas, J C (2006) Personality and everyday functioning, John Wiley and Sons, Hoboken, NJ.

Yelloly, M and Henkel, M (1995) Learning and teaching in social work: towards reflective practice (2nd edn.), Jessica Kingsley Publishers, UK

Zachar, P (2000) Psychological Concepts and Biological Psychiatry: A Philosophical Analysis, John Benjamins Publishing Company, USA

The Cutlass grew busier as the night wore on. Merchant sailors crowded in from their ships and the locals were quick into position to feed upon them. Regis and Wulfgar remained at the side table, the barbarian wide-eyed with curiosity at the sights around him, and the halfling intent on cautious observation.

Regis recognized trouble in the form of a woman sauntering toward them. Not a young woman, and with the haggard appearance all too familiar on the dockside, but her gown, quite revealing in every place that a lady’s gown should not be, hid all her physical flaws behind a barrage of suggestions. The look on Wulfgar’s face, his chin nearly level with the table, Regis thought, confirmed the halfling’s fears.

“Well met, big man,” the woman purred, slipping comfortably into the chair next to the barbarian.

Wulfgar looked at Regis and nearly laughed out loud in disbelief and embarrassment.

“You are not from Luskan,” the woman went on. “Nor do you bear the appearance of any merchants now docked in port. Where are you from?”

“The north,” Wulfgar stammered. “The dale…Icewind.”

Regis hadn’t seen such boldness in a woman since his years in Calimport, and he felt that he should intervene. There was something wicked about such women, a perversion of pleasure that was too extraordinary. Forbidden fruit made easy. Regis suddenly found himself homesick for Calimport. Wulfgar would be no match for the wiles of this creature.

“We are poor travelers,” Regis explained, emphasizing the “poor” in an effort to protect his friend. “Not a coin left, but with many miles to go.”

Wulfgar looked curiously at his companion, not quite understanding the motive behind the lie.

The woman scrutinized Wulfgar once again and smacked her lips. “A pity,” she groaned, and then asked Regis, “Not a coin?”

Regis shrugged helplessly.

“A pity it is,” the woman repeated, and she rose to leave.

Wulfgar’s face blushed a deep red as he began to comprehend the true motives behind the meeting.

Something stirred in Regis, as well. A longing for the old days, running in Calimport’s bowery, tugged at his heart beyond his strength to resist. As the woman started past him, he grabbed her elbow. “Not a coin,” he explained to her inquiring face, “but this.” He pulled the ruby pendant out from under his coat and set it dangling at the end of its chain. The sparkles caught the woman’s greedy eye at once and the magical gemstone sucked her into its hypnotic entrancement. She sat down again, this time in the chair closest to Regis, her eyes never leaving the depths of the wondrous, spinning ruby.

Only confusion prevented Wulfgar from erupting in outrage at the betrayal, the blur of thoughts and emotions in his mind showing themselves as no more than a blank stare.

Regis caught the barbarian’s look, but shrugged it away with his typical penchant for dismissing negative emotions, such as guilt. Let the morrow’s dawn expose his ploy for what it was; the conclusion did not diminish his ability to enjoy this night. “Luskan’s night bears a chill wind,” he said to the woman.

She put a hand on his arm. “We’ll find you a warm bed, have no fear.”

The halfling’s smile nearly took in his ears.

Wulfgar had to catch himself from falling off of his chair.

* * *

Bruenor regained his composure quickly, not wanting to insult Whisper, or to let her know that his surprise in finding a woman gave her a bit of an advantage over him. She knew the truth, though, and her smile left Bruenor even more flustered. Selling information in a setting as dangerous as Luskan’s dockside meant a constant dealing with murderers and thieves, and even within the structure of an intricate support network it was a job that demanded a hardened hide. Few who sought Whisper’s services could hide their obvious surprise at finding a young and alluring woman practising such a trade.

Bruenor’s respect for the informant did not diminish, though, despite his surprise, for the reputation Whisper had earned had come to him across hundreds of miles. She was still alive, and that fact alone told the dwarf that she was formidable.

Drizzt was considerably less taken aback by the discovery. In the dark cities of the drow elves, females normally held higher stations than males, and were often more deadly. Drizzt understood the advantage Whisper carried over male clients who tended to underestimate her in the male-dominated societies of the dangerous northland.

Anxious to get this business finished and get back on the road, the dwarf came straight to the purpose of the meeting. “I be needing a map,” he said, “and been told that yerself was the one to get it.”

“I possess many maps,” the woman replied coolly.

“One of the north,” Bruenor explained. “From the sea to the desert, and rightly naming the places in the ways o’ what races live there!”

Whisper nodded. “The price shall be high, good dwarf,” she said, her eyes glinting at the mere notion of gold.

Bruenor tossed her a small pouch of gems. “This should pay for yer trouble,” he growled, never pleased to be relieved of money.

Whisper emptied the contents into her hand and scrutinized the rough stones. She nodded as she slipped them back into the pouch, aware of their considerable value.

“Hold!” Bruenor squawked as she began to tie the pouch to her belt. “Ye’ll be taking none o’ me stones till I be seeing the map!”

“Of course,” the woman replied with a disarming smile. “Wait here. I shall return in a short while with the map you desire.” She tossed the pouch back to Bruenor and spun about suddenly, her cloak snapping up and carrying a gust of the fog with it. In the flurry, there came a sudden flash, and the woman was gone.

Bruenor jumped back and grabbed at his axe handle. “What sorcerous treachery is this?” he cried.

Drizzt, unimpressed, put a hand on the dwarf’s shoulder. “Calm, mighty dwarf,” he said. “A minor trick and no more, masking her escape in the fog and the flash.” He pointed toward a small pile of boards. “Into that sewer drain.”

Bruenor followed the line of the drow’s arm and relaxed. The lip of an open hole was barely visible, its grate leaning against the warehouse wall a few feet farther down the alley.

“Ye know these kind better than meself, elf,” the dwarf stated, flustered at his lack of experience in handling the rogues of a city street. “Does she mean to bargain fair, or do we sit here, set up for her thievin’ dogs to plunder?”

“No to both,” answered Drizzt. “Whisper would not be alive if she collared clients for thieves. But I would hardly expect any arrangement she might strike with us to be a fair bargain.”

Bruenor took note that Drizzt had slipped one of his scimitars free of its sheath as he spoke. “Not a trap, eh?” the dwarf asked again, indicating the readied weapon.

“By her people, no,” Drizzt replied. “But the shadows conceal many other eyes.”

* * *

More eyes than just Wulfgar’s had fallen upon the halfling and the woman.

The hardy rogues of Luskan’s dockside often took great sport in tormenting creatures of less physical stature, and halflings were among their favorite targets. This particular evening, a huge, overstuffed man with furry eyebrows and beard bristles that caught the foam from his ever-full mug dominated the conversation at the bar, boasting of impossible feats of strength and threatening everybody around him with a beating if the flow of ale slowed in the least.

All of the men gathered around him at the bar, men who knew him, or of him, nodded their heads in enthusiastic agreement with his every word, propping him up on a pedestal of compliments to dispel their own fears of him. But the fat man’s ego needed further sport, a new victim to cow, and as his gaze floated around the perimeter of the tavern, it naturally fell upon Regis and his large, but obviously young friend. The spectacle of a halfling wooing the highest priced lady at the Cutlass presented an opportunity too tempting for the fat man to ignore.

“Here now, pretty lady,” he slobbered, ale spouting with every word. “Think the likes of a half-a-man’ll make the night for ye?” The crowd around the bar, anxious to keep in the fat man’s high regard, exploded into overzealous laughter.

The woman had dealt with this man before and she had seen others fall painfully before him. She tossed him a concerned look, but remained firmly tied to the pull of the ruby pendant. Regis, though, immediately looked away from the fat man, turning his attention to where he suspected the trouble most likely would begin – to the other side of the table and Wulfgar.

He found his worries justified. The proud barbarian’s knuckles whitened from the grasp he had on the table, and the seething look in his eye told Regis that he was on the verge of exploding.

“Let the taunts pass!” Regis insisted. “This is not worth a moment of your time!”

Wulfgar didn’t relax a bit, his glare never releasing his adversary. He could brush away the fat man’s insults, even those cutting at Regis and the woman. But Wulfgar understood the motivation behind those insults. Through exploitation of his less-able friends, Wulfgar was being challenged by the bully. How many others had fallen victim to this hulking slob? he wondered. Perhaps it was time for the fat man to learn some humility.

Recognizing some potential for excitement, the grotesque bully came a few steps closer.

“There, move a bit, half-a-man,” he demanded, waving Regis aside.

Regis took a quick inventory of the tavern’s patrons. Surely there were many, in here who might jump in for his cause against the fat man and his obnoxious cronies. There was even a member of the official city guard, a group held in high respect in every section of Luskan.

Regis interrupted his scan for a moment and looked at the soldier. How out of place the man seemed in a dog-infested spittoon like the Cutlass. More curious still, Regis knew the man as Jierdan, the soldier at the gate who had recognized Drizzt and had arranged for them to pass into the city just a couple of hours earlier.

The fat man came a step closer, and Regis didn’t have time to ponder the implications.

Hands on hips, the huge blob stared down at him. Regis felt his heart pumping, the blood coursing through his veins, as it always did in this type of on-the-edge confrontation that had marked his days in Calimport. And now, like then, he had every intention of finding a way to run away.

But his confidence dissipated when he remembered his companion.

Less experienced, and Regis would be quick to say, “less wise!” Wulfgar would not let the challenge go unanswered. One spring of his long legs easily carried him over the table and placed him squarely between the fat man and Regis. He returned the fat man’s ominous glare with equal intensity.

The fat man glanced to his friends at the bar, fully aware that his proud young opponent’s distorted sense of honor would prevent a first strike. “Well, look ye here,” he laughed, his lips turned back in drooling anticipation, “seems the young one has a thing to say.”

He started slowly to turn back on Wulfgar, then lunged suddenly for the barbarian’s throat, expecting that his change in tempo would catch Wulfgar by surprise.

But although he was inexperienced in the ways of taverns, Wulfgar understood battle. He had trained with Drizzt Do’Urden, an ever-alert warrior, and had toned his muscles to their sharpest fighting edge. Before the fat man’s hands ever came near his throat, Wulfgar had snapped one of his own huge paws over his opponent’s face and had driven the other into the fat man’s groin. His stunned opponent found himself rising into the air.

For a moment, onlookers were too amazed to react at all, except for Regis, who slapped a hand across his own disbelieving face and inconspicuously slid under the table.

The fat man outweighed three average men, but the barbarian brought him up easily over the top of his seven-foot frame, and even higher, to the full extension of his arms.

Howling in helpless rage, the fat man, ordered his supporters to attack. Wulfgar watched patiently for the first move against him.

The whole crowd seemed to jump at once. Keeping his calm, the trained warrior searched out the tightest concentration, three men, and launched the human missile, noting their horrified expressions just before the waves of blubber rolled over them, blasting them backward. Then their combined momentum smashed an entire section of the bar from its supports, knocking the unfortunate innkeeper away and sending him crashing into the racks holding his finest wines.

Wulfgar’s amusement was short-lived, for other ruffians were quickly upon him. He dug his heels in where he was, determined to keep his footing, and lashed out with his great fists, swatting his enemies aside, one by one, and sending them sprawling into the far corners of the room. Fighting erupted all around the tavern. Men who could not have been spurred to action if a murder had been committed at their feet sprang upon each other with unbridled rage at the horrifying sight of spilled booze and a broken bar.

Few of the fat man’s supporters were deterred by the general row, though. They rolled in on Wulfgar, wave after wave. He held his ground well, for none could delay him long enough for their reinforcements to get in. Still, the barbarian was being hit as often as he was connecting with his own blows. He took the punches stoically, blocking out the pain through sheer pride and his fighting tenacity that simply would not allow him to lose.

From his new seat under the table, Regis watched the action and sipped his drink. Even the barmaids were into it now, riding around on some unfortunate combatants’ backs, using their nails to etch intricate designs into the men’s faces. In fact, Regis soon discerned that the only other person in the tavern who wasn’t in the fight, other than those who were already unconscious, was Jierdan. The soldier sat quietly in his chair, unconcerned with the brawling beside him and interested only, it seemed, in watching and measuring Wulfgar’s prowess.

This, too, disturbed the halfling, but once again he found that he didn’t have time to contemplate the soldier’s unusual actions. Regis had known from the start that he would have to pull his giant friend out of this, and now his alert eyes had caught the expected flash of steel. A rogue in the line directly behind Wulfgar’s latest opponents had drawn a blade.

“Damn!” Regis muttered, setting down his drink and pulling his mace from a fold in his cloak. Such business always left a foul taste in his mouth.

Wulfgar threw his two opponents aside, opening a path for the man with the knife. He charged forward, his eyes up and staring into those of the tall barbarian. He didn’t even notice Regis dart out from between Wulfgar’s long legs, the little mace poised to strike. It slammed into the man’s knee, shattering the kneecap, and sent him sprawling forward, blade exposed, toward Wulfgar.

Wulfgar side-stepped the lunge at the last moment and clasped his hand over the hand of his assailant. Rolling with the momentum, the barbarian knocked aside the table and slammed into the wall. One squeeze crushed the assailant’s fingers on the knife hilt, while at the same time Wulfgar engulfed the man’s face with his free hand and hoisted him from the ground. Crying out to Tempus, the god of battle, the barbarian, enraged at the appearance of a weapon, slammed the man’s head through the wooden planks of the wall and left him dangling, his feet fully a foot from the floor.

An impressive move, but it cost Wulfgar time. When he turned back toward the bar, he was buried under a flurry of fists and kicks from several attackers.

* * *

“Here she comes,” Bruenor whispered to Drizzt when he saw Whisper returning, though the drow’s heightened senses had told him of her coming long before the dwarf was aware of it. Whisper had only been gone a half-hour or so, but it seemed much longer to the two friends in the alley, dangerously open to the sights of the crossbowmen and other thugs they knew were nearby.

Whisper sauntered confidently up to them. “Here is the map you desire,” she said to Bruenor, holding up a rolled parchment.

“A look, then,” the dwarf demanded, starting forward.

The woman recoiled and dropped the parchment to her side. “The price is higher,” she stated flatly. “Ten times what you have already offered.”

Bruenor’s dangerous glare did not deter her. “No choice is left to you,” she hissed. “You shall find no other who can deliver this unto you. Pay the price and be done with it!”

“A moment,” Bruenor said with sudden calm. “Me friend has a say in this.” He and Drizzt moved a step away.

“She has discovered who we are,” the drow explained, though Bruenor had already come to the same conclusion. “And how much we can pay.”

“Be it the map?” Bruenor asked.

Drizzt nodded. “She would have no reason to believe that she is in any danger, not down here. Have you the money?”

“Aye,” said the dwarf, “but our road is long yet, and I fear we’ll be needing what I’ve got and more.”

“It is settled then,” Drizzt replied. Bruenor recognized the fiery gleam that flared up in the drow’s lavender eyes. “When first we met this woman, we struck a fair deal,” he went on. “A deal we shall honor.”

Bruenor understood and approved. He felt the tingle of anticipation start in his blood. He turned back on the woman and noticed at once that she now held a dagger at her side instead of the parchment. Apparently she understood the nature of the two adventurers she was dealing with.

Drizzt, also noticing the metallic glint, stepped back from Bruenor, trying to appear unmenacing to Whisper, though in reality, he wanted to get a better angle on some suspicious cracks that he had noticed in the wall – cracks that might be the edgings of a secret door.

Bruenor approached the woman with his empty arms outstretched. “If that be the price,” he grumbled, “then we have no choice but to pay. But I’ll be seein’ the map first!”

Confident that she could put her dagger into the dwarf’s eye before either of his hands could get back to his belt for a weapon, Whisper relaxed and moved her empty hand to the parchment under her cloak.

But she underestimated her opponent.

Bruenor’s stubby legs twitched, launching him up high enough to slam his helmet into the woman’s face, splattering her nose and knocking her head into the wall. He went for the map, dropping the original purse of gems onto Whisper’s limp form and muttering, “As we agreed.”

Drizzt, too, had sprung into motion. As soon as the dwarf flinched, he had called upon the innate magic of his heritage to conjure a globe of darkness in front of the window harboring the crossbowmen. No bolts came through, but the angered shouts of the two archers echoed throughout the alley.

Then the cracks in the wall split open, as Drizzt had anticipated, and Whisper’s second line of defense came rushing through. The drow was prepared, scimitars already in his hands. The blades flashed, blunt sides only, but with enough precision to disarm the burly rogue that stepped out. Then they came in again, slapping the man’s face, and in the same fluidity of motion, Drizzt reversed the angle, slamming one pommel, and then the other, into the man’s temples. By the time Bruenor had turned around with the map, the way was clear before them.

Bruenor examined the drow’s handiwork with true admiration.

Then a crossbow quarrel ticked into the wall just an inch from his head.

“Time to go,” Drizzt observed.

“The end’ll be blocked, or I’m a bearded gnome,” Bruenor said as they neared the exit to the alley. A growling roar in the building beside them, followed by terrified screams, brought them some comfort.

“Guenhwyvar,” Drizzt stated, as two cloaked men burst out into the street before them and fled without looking back.

“Sure that I’d forgotten all about that cat!” cried Bruenor.

“Be glad that Guenhwyvar’s memory is greater than your own,” laughed Drizzt, and Bruenor, despite his feelings for the cat, laughed with him. They halted at the end of the alley and scouted the street. There were no signs of any trouble, though the heavy fog provided good cover for a possible ambush.

“Take it slow,” Bruenor offered. “We’ll draw less attention.”

Drizzt would have agreed, but then a second quarrel, launched from somewhere down the alley, knocked into a wooden beam between them.

“Time to go!” Drizzt stated more decisively, though Bruenor needed no further encouragement, his little legs already pumping wildly as he sped off into the fog.

They made their way through the twists and turns of Luskan’s rat maze, Drizzt gracefully gliding over any rubble barriers and Bruenor simply crashing through them. Presently, they grew confident that there was no pursuit, and they changed their pace to an easy glide.

The white of a smile showed through the dwarf’s red beard as he kept a satisfied eye cocked over his shoulder. But when he turned back to view the road before him, he suddenly dove down to the side, scrambling to find his axe.

He had come face up with the magical cat.

Drizzt couldn’t contain his laughter.

“Put the thing away!” Bruenor demanded.

“Manners, good dwarf,” the drow shot back. “Remember that, Guenhwyvar cleared our escape trail.”

“Put it away!” Bruenor declared again, his axe swinging at the ready.

Drizzt stroked the powerful cat’s muscled neck. “Do not heed his words, friend,” he said to the cat. “He is a dwarf, and cannot appreciate the finer magics!”

“Bah!” Bruenor snarled, though he breathed a bit easier as Drizzt dismissed the cat and replaced the onyx statue in his pouch.

The two came upon Half-Moon Street a short while later, stopping in a final alley to look for any signs of ambush. They knew at once that there had been trouble, for several injured men stumbled, or were carried, past the alley’s entrance.

Then they saw the Cutlass, and two familiar forms sitting on the street out in front.

“What’re ye doin’ out here?” Bruenor asked as they approached.

“Seems our big friend answers insults with punches,” said Regis, who hadn’t been touched in the fray. Wulfgar’s face, though, was puffy and bruised, and he could barely open one eye. Dried blood, some of it his own, caked his fists and clothes.

Drizzt and Bruenor looked at each other, not too surprised.

“And our rooms?” Bruenor grumbled.

Regis shook his head. “I doubt it.”

“And my coins?”

Again the halfling shook his head.

“Bah!” snorted Bruenor, and he stamped off toward the door of the Cutlass.

“I wouldn’t…” Regis started, but then he shrugged and decided to let Bruenor find out for himself.

Bruenor’s shock was complete when he opened the tavern door. Tables, glass, and unconscious patrons lay broken all about the floor. The innkeeper slumped over one part of the shattered bar, a barmaid wrapping his bloodied head in bandages. The man Wulfgar had implanted into the wall still hung limply by the back of his head, groaning softly, and Bruenor couldn’t help but chuckle at the handiwork of the mighty barbarian. Every now and then, one of the barmaids, passing by the man as she cleaned, gave him a little push, taking amusement at his swaying.

“Good coins wasted,” Bruenor surmised, and he walked back out the door before the innkeeper noticed him and set the barmaids upon him.

“Hell of a row!” he told Drizzt when he returned to his companions. “Everyone in on it?”

“All but one,” Regis answered. “A soldier.”

“A soldier of Luskan, down here?” asked Drizzt, surprised by the obvious inconsistency.

Regis nodded. “And even more curious,” he continued, “it was the same guard, Jierdan, that let us into the city.” Drizzt and Bruenor exchanged concerned looks.

“We’ve killers at our backs, a busted inn before us, and a soldier paying us more mind than he should,” said Bruenor.

“Time to go,” Drizzt responded for the third time.

Wulfgar looked at him incredulously. “How many men did you down tonight?” Drizzt asked him, putting the logical assumption of danger right out before him. “And how many of them would drool at the opportunity to put a blade in your back?”

“Besides,” added Regis before Wulfgar could answer, “I’ve no desire to share a bed in an alley with a host of rats!”

“Then to the gate,” said Bruenor.

Drizzt shook his head. “Not with a guard so interested in us. Over the wall, and let none know of our passing.”

* * *

An hour later, they were trotting easily across the open grass, feeling the wind again beyond the break of Luskan’s wall.

Regis summed up their thoughts, saying, “Our first night in our first city, and we’ve betrayed killers, fought down a host of ruffians, and caught the attention of the city guard. An auspicious beginning to our journey!”

“Aye, but we’ve got this!” cried Bruenor, fairly bursting with anticipation of finding his homeland now that the first obstacle, the map, had been overcome.

Little did he or his friends know, however, that the map he clutched so dearly detailed several deadly regions, one in particular that would test the four friends to their limits – and beyond.

Introduction

This essay discusses the legal and ethical issues arising from a scenario where Sarah, aged 86 who is a retired nurse has refused to undergo invasive medical treatment for a condition that is likely to lead to death. Having inquired and been informed of what the procedure will entail, she instead requested for only palliative care. According to the facts, Sarah’s pain was at point 6 on the Trust pain score. Most importantly, the facts are state that “Morphine 10mgs IV was keeping Sarah pain free; this was being given every 4 – 6 hours.” Impliedly Sarah’s mental capacity to consent or decline treatment is not vitiated by the pain she was previously feeling. She is competent and clear about her decision. However, family members disagree and think she is incompetent. Several human rights, legal and ethical issues arise and are discussed with reference to the Human Rights Act 1998 and the Mental Capacity Act 2005. The Human Rights Act 1998 made rights guaranteed by the European Convention on Human Rights (hereafter ‘ECHR’) enforceable in United Kingdom courts.

It is submitted that the scenario raises three human rights issues. Firstly is the right to life enshrined in Article 2 of the European Convention on Human Rights. It is open for the family members to argue that letting Sarah to die will violate her right to life (Pretty v United Kingdom [2002]).Sarah however, cannot argue that she has a right to die. Such an assertion was rejected by the European Court of Human Rights (Pretty v United Kingdom [2002]). Nevertheless, one has a right to reject medical treatment. Secondly, article 3 ECHR that forbids inhuman and degrading treatment could be invoked. If treated despite her refusal of treatment, Sarah may sue for violation of right not to be subjected to inhuman and degrading treatment (Herring, J, 2010, p. 146; R (N) v Dr. M., A Health authority Trust and Dr. O [2002].This right was also affirmed in the case of Trust A, Trust B v H (an Adult Patient) (Represented by her Litigation Friend, the Official Solicitor. As explained by the Court of Appeal, it is consent that gives a medical professional the legal ‘flak jacket’ or defence to a legal action against them (Herring, J, 2010; Re W [1992]). However, the family members could paternalistically argue that failure to treat Sarah and leaving her to die would violate article 8 of the European Convention on Human Rights which guarantees their right to family life (G v E (2010)); Paton v United Kingdom). However, as decided in Pretty’s case, Sarah’s rights will have to be respected however irrational they may be.Sarah’s choice to have palliative care and be transferred to a hospice to die is also arguable. It raises an issue of whether she has a right to make this choice.Court has held that the right to life does not mean that a patient is entitled to make a choice of the treatment they would like(R. (on the application of Burke) v General Medical Council [2005] para. 31). The NHS just like any other health care system has resource constraints and is not in position to give specific treatment to particular patients. Further, Sarah’s right to private life guaranteed by article 8 ECHR could also be engaged. The recommended treatment would be invasive and if given without her consent would be a breach of her privacy as affirmed by Evans v UK (2007). It is therefore submitted that the healthcare professionals should not act against Sarah’s wishes.

A central issue is whether Sarah had the right to refuse medical treatment. It is a fundamental principle of law that before treating a competent adult patient like Sarah, consent should be obtained (Herring, J, 2010, p. 146; McHale J. and Fox, M, 2007, p. 360; Jackson, E, 2010, p. 167). This had been recognised as early as 1767 in the case of Slater v Baker and Stapleton. Even before the enactment of the Human Rights Act, Lord Scarman in 1985 stated to the effect that a patient had a ‘basic human right’ to make her own medical decisions (Jackson, 2010, p. 182). In 1914 an American Judge, Cardozo, J had stated that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body…”(Schloendorff v New York Hospital cited in Jackson, E. 2010, at p. 216-217.). An extreme statement of this rule is that competent adult patients have the right to make irrational and life-threatening decisions to refuse medical treatment (Jackson, E., 2010, p. 221; case). The General Medical Council in England has advised its members along same lines (British Medical Association, 2007, para. 25.5). The rule is based on the cardinal principle of patient autonomy and the right to self determination (Herring, J, p. 147; McHale, J, et al, 2007, 354-350). Applying the law to this scenario, it is emphatically submitted that Sarah had the right to make the decision.

Having resolved the question of whether she had the right to make the decision, the next important question is whether she had the mental capacity to do so and whether she did so in the right way.A patient can only exercise the right to consent to or refuse medical treatment if they have the capacity or competence to do so (Re F [1990]). While it is the law that everyone is presumed to have capacity unless it is established to the contrary (section 2(1) Mental Capacity Act 2005), the presumption of capacity to consent or refuse treatment is rebuttable. This is where other parties such as the healthcare professionals and family members may be involved. Nevertheless, it should be emphasised that even if the patient were incompetent, it does not follow that the family members can make the decision on her behalf (Herring, J, 2010, p. 150). To resolve the capacity issue, it is imperative to determine what legally is meant by lack of capacity. According to section 2(1) of the Mental Capacity Act 2005, which (Act) codified and improved on the common law rules governing consent, “a person lacks capacity in relation to a matter “if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain”. Though not expressly stipulated, the Mental Capacity Act presumption is with respect to adults who are over the age of 16 (Jackson, E., 2010; Johnston and Liddle, 2007, 94-97, at. 94). Owing to the presumption of capacity that applies to every adult including Sarah, it will be up to the dissenting family members prove that she is incapacitated. On the facts, Sarah was capable of comprehending and retaining, weighing and communicating a decision (Re C (refusal of Medical Treatment) [1994]; Mason, et al, 2011). In case there is reason for doubt, capacity has to be assessed again.

Arguably, the family members’ could rely on the fact that Sarah’s ailment is causing pain which may have rendered her temporarily incompetent to consent (section 2(2) of the Mental Capacity Act). Even according to the Mental Capacity Act Code of Practice (paragraphs 4.26) acute illness, severe pain or the effect of medication may affect someone’s ability to make decisions. The reply to this however is that since Sarah is being kept “pain-free” capacity is not affected. It is my contention that this reply would seriously weaken or even defeat the family members’ argument. Sarah’s advanced age cannot be used to imply incapacity. To do so would be contrary section 2(3) of the Mental Capacity Act 2005 (Jackson, E, 2010, p. 233).The family members’ argument may therefore fail.

All the available evidence suggests that Sarah was competent to decide. The burden will therefore be on the family to show that this was not the case. Sarah raised questions for the doctor to answer, got the answers and then made her decision which she communicated. She even anticipated that her family would not agree with her and prepared to explain to them. Arguably, she exceeded the standards of retention mentioned in section 3(3) of the Mental Capacity Act since her retention was more than temporary. She fully understood the nature and purpose of the recommended surgery (F v W. Berkshire HA, per Lord Brandon, [1989] 2 All ER 545). The family is thus most likely not to satisfy the burden of proving as required in the cases of Re MB (An Adult: Medical Treatment(1997)) and Re C (Adult: Refusal of Treatment).

Alternatively family members could argue that Sarah did not give ‘informed consent’ as required by English law (Jackson, 2010). However, considering that she is a retired nurse and that she asked and information was given, this ground of attack may not be accepted by the court. The specific questions she raised support the fact that she understood what was explained and hence her consent was from an informed point of view. Nevertheless, it could be argued that she did not get sufficient information. This is because she did not actually get a reply to the question of Intensive Care Unit. The doctor replied that this would depend on the anaesthetists. There is no evidence that their opinion was given to Sarah as required by Sidaway v Board of Governors of the Bethlem Royal Hospital and Maudsley Hospital [1985] (also Jackson, 2010; Montgommery, 2003). The family members could take the matter to the Court of Protection established under section 45 of the Mental Capacity Act 2005 for a decision. However, it would be advisable for the family to use persuasion. A patient has a right to change her mind at any time since consent is a continuing process. The law is less stringent on proving acceptance of treatment than on refusal arguably to promote sanctity of life and beneficence principles.

Yet another important legal aspect to consider is whether the ‘informed consent’ was given voluntarily-without any coercion or undue influence (In Re T (Adult: Refusal of Medical Treatment) 1993 Fam 95). As the facts stand, there is nothing to suggest that there was any undue influence or coercion. However, should the family talk to the patient and she changes their mind, this might be reason to prove that the consent has not been given voluntarily. This would then put the healthcare professionals at the risk of being sued for battery in case they go ahead to treat Sarah who has preferred to exercise her right to autonomy and bodily integrity (Jackson, E., 2010, p. 219). Any such actions would go against the principles laid down in the case of Re T (Adult Patient: Refusal of Medical Treatment case [2004] involving a Jehovah witness patient that changed their mind to refuse treatment after talking to the mother.Sarah is a competent adult and her decision is in line with the principles of patient autonomy and self determination as well as the right to bodily integrity. The fact that she has made what looks to the family members as an unwise or irrational decision is immaterial (section 1(4) Mental Capacity Act 2005). As observed in the Re T (Adult Patient: Refusal of Medical Treatment case [2004] the question of mental capacity should not be confused with the nature of the decision since the view of the patient may reflect difference in values rather than absence of competence. Though capacity should not be decided in reference to age, it is arguable that Sarah’s values may be different to those of other family members. She values not being subjected to intrusive medical treatment which is consistent with her right to bodily integrity. This does not mean she is incompetent.

Apart from the legal issues involved in this scenario there are also ethical issues arising. While the principle of autonomy has been upheld and should be applied to let Sarah’s decision stand,such would not be in tandem with utilitarianism. It does not look at the interests of the majority who are the family members who would like to keep their relative alive. These family members have to look after her even when she is on palliative care in the hospice. This gives credence to a possible argument that Sarah was unable to weigh the impact of her decisions on the rest of the family members.Further, her actions do not bring ‘happiness’ in the utilitarian sense (Jackson, E., 2010) at least to the family members who are the greatest number. But in this case, this is an elderly woman and arguably, she is entitled to be allowed to depart the way she chooses. This is one way of following the Kantian ethics because humanity should not be treated as a means but always as an end (Jackson, E., 2010, p. 12). Further, disregarding the wishes of Sarah in this case would mean that justice is not being done equally to her. Kant advocated for universal laws that apply the same way to everyone (Jackson, E, p. 12). Patient autonomy is an established and tested principle of law.

The other issue is to do with the principle of beneficence. Accepting not to treat Sarah is generally not good. Healthcare practitioners are supposed to do good which does not imply not taking any action. Beneficence looks at the concept of ‘good’ from the non-material point of view. Arguably, Sarah seems to be promoting different values, of dying with bodily integrity. In terms of virtue ethics, the patient autonomy principle of respecting Sarah’s decision to die when she has a chance to live is not the right decision. Her life at 86 cannot be said to lack the most basic human goods (Jackson, E, p. 13). Even from a deontological point of view, it is intrinsically wrong to let someone die because of promoting patient autonomy. It is contended that patient autonomy indirectly grants a ‘right to die’ contrary to the law. Finally using a consequentialist approach, resources should be concentrated where they promote the maximum possible welfare for the maximum number of people, notably promoting the quality of life rather than sanctity of life. It might mean that resources should be allocated to prevention rather than cure.

In conclusion, important human rights, legal and ethical issues have been raised and discussed. The central one was whether there was consent as required by law. It has been argued basing on the fact that the patient is being kept pain-free by morphine, and based on the presumption of capacity the family members have a weak case. Sarah has a right to decline treatment and she exercised it while (in our view) having the mental capacity to do so. While this goes against other ethical considerations, the paramount consideration is Sarah’s competent opinion, however irrational it may be. The scenario shows how contentious determining consent can be. Even where it looks clear, relatives may sue healthcare professionals pursuant to the Human Rights Act. Whether the challenges succeed is for the court to decide based on evidence.

References

Bartlett, P., and Sandland, R, (2007), Mental Health Law: Policy and Practice, Oxford University Press (Chapter 10, Mental Capacity).

Brazier, M., and Cave, E., (2007), Medicine, Patients and the Law, 4th Ed. Penguin Books

Jackson, E. (2010), Medical Law: Text, Cases and Materials, Oxford University Press, Oxford.

McHale, J, et al (2007), Health Care Law: Text and materials, Sweet and Maxwell.

Mason, J.K., et al, (2006), Mason and McCall Smith’s Law and Medical Ethics, Oxford University Press.

Montgommeryy, J, (2003), Health Care Law, Oxford University Press

Acts and Conventions

Convention for the Protection of Human Rights and Fundamental Freedoms
as amended by Protocols No. 11 and No. 14 (accessed on 15.06 2012 at:

http://conventions.coe.int/Treaty/en/Treaties/html/005.htm).

Human Rights Act (1998)

Article 2 – the Right to Life
Article 3- Article 3- Right not to be subjected to degrading treatment
Article 8 – Right to Respect for Private and Family Life

– The Mental Capacity Act (2005)

Case Law

Airedale NHS Trust v Bland 1993 AC 789

Bethlem Royal Hospital and Maudsley Hospital [1985] AC 871

Chester v Afshar [2004] UKHL 41

Evans v UK (2007) 43 EHRR 21

F v W. Berkshire HA [1989] 2 All ER 545

Re JT [1998] 1FLR 48 (FD)

Markose v Epsom & St Helier NHS Trust [2004] EWHC 3130 (QB)

Paton v United Kingdom3 EHRR 408 1980

Pretty v United Kingdom [2002] 2 FLR 612

R v Lancashire HA ex parte A (2000) 2 FCR 525

(on the application of Burke) v General Medical Council [2005] Q.B. 424http://login.westlaw.co.uk/maf/wluk/app/document?src=doc&linktype=ref&&context=9&crumb-action=replace&docguid=I16EE5690673D11E18ED7DEE3C0946BB5

Re B (Adult: Refusal of Medical Treatment) 2002 EWHC (Fam.)

Re C (Adult: Refusal of Treatment) 1993 Fam 95

Re F [1990] 2 A.C. 1

Re MB (An Adult: Medical treatment) [1997] 2 FLR 426

R (N) v Dr. M., A Health authority Trust and Dr. O [2002] EWHC 1911

Re T (Adult: Refusal of Medical Treatment) 1993 Fam 95

Re W [1992] 4 All ER 627, 633–

Savage v South Essex partnership NHS Foundation trust (2006) EWHC 3562

Schoelendorff v New York hospital 211 N.Y. 125 1914

Slater v Baker and Stapleton [1767] 8 Geo 111 860

Trust A, Trust B v H (an Adult Patient) (Represented by her Litigation Friend, the Official Solicitor)[2006] EWHC 1230(Fam)

Others:

Mental Capacity Act Code of Practice; (accessed on 20.06.2012 at: www.dca.gov.uk/legal-policy/mental–capacity/mca-cp.pdf).

Journal articles

Johnston, C., and Liddle, J. (2007), The Mental Capacity Act 2006: a new framework forhealthcare decision making, Journal of Medical Ethics,2007; 33:94-97

MacLean, A., (2012), ‘From Sidaway to Pearce and beyond: is the legal regulation ofconsent any better following a quarter of a century of judicial scrutiny?’ Med. L. Rev. 2012, 20(1), 108-129

Mallardi, V, The origin of Informed Consent, (Abstract written in English, Article in Italian) giving historical origins of the doctrine of informed consent dating way back to ancient Greeks and Egyptians (accessed on 15.06.2012 at: http://www.ncbi.nlm.nih.gov/pubmed/16602332.

Shaw, J (1986), Informed consent: a German lesson (1986) International & Comparative Law Quarterly 864

Stein R, and Frances Swaine (2002), Ms B v An NHS Trust: the patient’s right to choose, 152 NLJ 642

Stirrat, G M and Gill, R, Autonomy in medical ethics after O’Neill, J Med Ethics 2005; 31:127–130

Introduction

Africa with an average annual GDP/capita amounting to $1,560 is the poorest continent in the world, as Appendix 1 demonstrates (World Bank, 2012). Most countries of the region struggle with a number of socio-economic problems. African states are economically underdeveloped. They are characterized by low GDP/capita, high inflation and high unemployment rates. With the exception of seven oil-exporting countries[1], Africa states are relatively poor in natural resources. As most of them failed to industrialize, the major component of GDP in Africa remains agriculture. In result, they are global net importers. At the same time, most of them grapple with unstable exchange regime and huge national debts. At the social level, African countries are overpopulated and unable to provide free health care and education to their citizens. Hence, they are characterized by spreading diseases and high illiteracy rate. Further most of them fail to provide equal income redistribution. Hence, spreading poverty became a permanent feature of contemporary African states. Many scholars and African activists believe that corruption is a key obstacle to overcoming internal crises and to socio-economic progress on the African continent. Although international bodies and some national governments (i.e. Nigeria) have implemented anti-corruption strategies in the recent years, a little progress has yet been observed. In 2011, Transparency International has still listed all African states but Botswana as highly corrupted states (Appendix 2).

The following essay is an in-depth analysis of clientelism[2] and corruption problems in Africa, aiming to demonstrate why these problems remain inherent elements of political regimes in Africa. First, the following essay presents a short overview of the corruption problem on the African continent. Further, the essay examines why combating corruption is such a challenge in most African states. In conclusions, the essay presents policy recommendations.

Clientelism and corruption on the Africa continent

Without a doubt Africa is strongly affected by the corruption problem. One of the best known corruption cases comes from Nigeria. The former dictator, general Abacha, had been stealing national oil revenues and had transferred them into his private account in Switzerland. The issue was revealed in 2005 (after general’s death) and Nigeria started to recover their funds (Lovejoy, 2008). Nonetheless, Nigeria is not a sole example in Africa. The Corruption Perception Index, the most popular corruption measure used by Transparency International is low for all African countries but Botswana[3]. In 2011, fifty three African states reached CPI between 0 and 5 and hence, were qualified as highly corrupted states. Botswana with its CPI amounting to 6.1 is the only African country where the corruption level can be comparable to the corruption levels in the European states such as Portugal (6.2) and Spain (6.1) (Transparency International, 2011).

Also Gini Coefficient Index, an international measure of income inequality, indirectly indicates the scale of corruption in Africa, as it measures how equally the incomes (wealth) are distributed within the society. According to the World Bank data[4] (2011), Gini Coefficient ranges from 35.3 in Sudan to 63.1 in South Africa. Hence, Gini Coefficient points out that the African states are characterized by highly unequal income redistribution and significant level of corruption.

The roots of clientelism and corruption in Africa

As African states are highly diversified at the political and socio-economic levels, various factors contribute to a current level of corruption. Three of them need to be considered. First of all, corruption is deep-rooted in African history and tradition. The colonial states in Africa had been characterized by the centralization of economic and political power. The colonial institutions such as police or security services that were meant to uphold the law, in fact served the colonial elites (i.e. governors, administrators). The elites had a privileged access to the colonial resources. They lived expensive lives and selectively shared resources within the colonial society. Violence was commonly used to deal with dissatisfaction amongst the colonial workers. Not only did the colonial elites fail to develop a culture of hard work but also encouraged unequal resources redistribution and so-called petty corruption amongst lower-level civil servants such as bribes for routine services (Konold, 2007). The new governments in postcolonial Africa that often remained highly centralized modeled on their colonial predecessors. Instead of establishing new political regimes, they fitted into colonial political structures. Hence, the colonial political systems with rooted corruption have been followed in Africa for over 50 years and still exist in a number of authoritarian African states such as Chad, Zimbabwe or Sudan (Gumede, 2012; Szeftel, 2000). Moreover, some scholars (i.e. Huntington) postulate that corruption was deepened in the postcolonial Africa. The political and socio-economic modernization resulted in the creation of new sources of wealth and in the expansion of the governmental authorities. The postcolonial governments, following the colonial authorities’ behaviours, reaped private benefits and had further developed unequal wealth redistribution (Konold, 2007).

Second, some political regimes in Africa are not aware of negative consequences of some forms of corruption. During the 1978 elections in Nigeria, presidential candidates offered material incentives in order to gain political support. After election, President Shagari signed a valuable dam contract. The revenues that could have contributed to socio-economic transformations in Nigeria had to cover high costs of presidential campaign (Magrin and Vliet, 2009). Many scholars believed that political transformation into modern democracy was a key factor to corruption reduction in Africa (Konold, 2007). However, current levels of corruption in democratic and non-democratic regimes in Africa are comparable (Transparency International, 2011). While non-democratic regimes in Africa simply regard corruption as an inherent element of their political systems, democratic states often practice bad behaviours such as clientelism and do not seem to notice negative consequences of these behaviours. Further, in some African countries (i.e. Zambia) clientelism led to the extreme situations where the national governments are no longer able to make policy in national interest. It is known as “Big Man Syndrome” or “bigmanism” (Lindberg, 2010, p.2). In the countries where economic conditions are poor, the governments offer non-material incentives in order to gain support. These incentives are usually governmental employment which results in a large bureaucracy. Hence, the governments are focused on securing their interests rather than overall national interests. They seem to be unable to tackle corruption.

Another problem is an underdeveloped private sector, characteristic for most African countries. The national governments became responsible for creating a capitalist class and businesses in postcolonial Africa. However, politicians and governmental officials occupied the major positions in the newly privatized companies. In result, also private sector in contemporary Africa remains weak and dependent on state. It does not require the government to become more accountable (Gumede, 2012).

Finally, the international efforts towards corruption combating in Africa do not bring positive outcomes. The fight against corruption in Africa has involved a number of international bodies such as the World Bank, the International Monetary Fund, European Union or Transparency International. The global anti-corruption strategies launched in Africa over the past years focused on the reduction of incentives and opportunities for corruption. Moreover, the international aid to Africa became dependent on good governance in African states. However, the implementation and synchronization of the anti-corruption reforms remained poor. International bodies undermined also collective action problem (Persson, 2010, p.12), characteristic for Africa. As corruption is a common feature of African governments, African societies often do not believe that reporting corruption cases could bring any change and hence, do not cooperate with international bodies. A significant obstacle remain also Western countries (in particular Switzerland) that welcome huge amounts of money and goods from Africa and seem to ignore the fact that these money are gained through corruption. Instead of cooperation with international bodies on corruption combating, these states indirectly support corruption development in Africa (Ogongo, 2012).

Conclusions: policy recommendations

To conclude, clientelism and corruption remain significant problems of the contemporary African continent. Not only are clientelism and corruption deep-rooted in the African tradition but they also seem to be underestimated by the national governments. These governments often fail to recognize negative consequences of corruption and to take appropriate actions. Some governments lost their ability to act in the national interest and to tackle corruption. Also international organizations often fail to deliver a coherent support in corruption combating to African governments. Additionally, their role is often undermined by the Western countries, accepting corrupt money from Africa.

Many scholars and African activists postulate that the elimination of corruption incentives is simply not a sufficient element to successful poverty combating. The African governments have to gain confidence within the societies. Hence, only radical transformations at the political, social and economic levels can bring positive outcomes to corruption reduction in Africa. The World Bank identified five key elements of corruption reduction in Africa. These elements are an increase of political accountability, strengthening civil society participation, institutional restrain on power, competitive private sector and better public sector management (Persson, 2010).

The following policy recommendations seem to be a good start for corruption reduction in Africa. First, the African ruling parties must establish a new type of leadership both at the national and local levels. The new leadership style should be characterized by the honesty, competence and a set of values encouraging socio-economic development. Further, the ruling parties should publicly punish bad behaviours and reward positive steps taken by the governmental officials. This kind of action will restore moral authority of the national governments amongst the citizens and will help the society to follow the established rules. Moreover, African media should be actively involved in the corruption problem in Africa in order to condemn publicly corruption cases and promote a new system of values within African societies (Gumede, 2012).

Literature:
Amundsen, , (1999). Political corruption: An Introduction to the issue. Bergen: Chr. Michelsen Institute
Gumede, W., (2012). Africans inherited corruption [online] Available from: The Sunday Independent < http://www.iol.co.za/sundayindependent/africans-inherited-corruption-1.1259448> (Accessed on 15/04/2012)
Konold, C., (2007). Perceived corruption, public opinion and social influence in Senegal. Working paper number 85. Michigan: University of Michigan
Lindberg, S., (2010). Some evidence on the demand side of private-public goods provision by MPs. London: Overseas Development Institute
Lovejoy, P., al., (2008). A country study. Nigeria. Washington: Federal Research Division
Magrin, G. and Vliet G., (2009). The use of oil revenues in Africa [In] Lesourne, J. (ed.), Governance of oil in Africa: unfinished business. Paris: IFRI, p.103-164
Ogongo, S., (2012). Reduce corruption in order to develop, author tells Africa [online] Available from: < http://www.africa-news.eu/africans-in-uk/4028-reduce-corruption-in-order-to-develop-author-tells-africa-.html> (Accessed on 15/04/2012)
Persson, A., (ed.), (2010). The failure of anti-corruption policies. A theoretical mischaracterization of the problem. Goteborg: University of Gothenburg
Szeftel, M., (2000). Clientelism, corruption and catastrophe. Review of African Political Economy, 85, p. 427-441
Transparency International, (2011). Corruption Perception Index 2011 [online] Available from: < http://cpi.transparency.org/cpi2011/results/> (Accessed on 15/04/2012)
The World Banka Database, (2011). [online] Available from: < http://data.worldbank.org/> (Accessed on 15/04/2012)

1. Introduction

The following essay considers the role that unconscious factors play in organisational life, and looks at the extent to which awareness of these factors amongst workers can improve outcomes for users. The idea is considered both in relation to appropriate literature and also in relation to my own experience of a social work organisation, the placement I experienced in a children’s home. The ways in which social work practice can be oppressive and anti-oppressive, and the impact of both of these for the user, are also explored. My interest in this area has been informed by my experience in a care home for children (Adeza) as a student social worker. I worked with a wide range of client groups including children (and their families) under stress, children (and their families with mental health problems, children at risk and children with physical and mental disabilities. I had a wide range of duties including administrative functions, advising clients and supporting children in a variety of ways. I became aware of the ways in which unconscious attitudes can impact upon the way clients and other staff are treated through a phenomenon I later learned was called projection, that is, the psychological mechanism whereby worries and fears about oneself are seen as present in other people, and demonised. For example, some clients had internalised a set of notions about being inadequate parents, which were then projected onto staff at the home, in a variety of ways.

2. The Notion of the Unconscious

Understanding human needs, wants and motivations is a central part not only of organizational theory but also of human psychology generally. Various theories have been proposed to explain the variety of behaviours which characterise human beings, for example behaviourism, which reduces the role of the ‘mental’ and looks at human actions in terms of stimulus and response (Baran and Davis 2011), and Weber’s idea of work as salvation (Nelson and Quick 2010). However, the notion of the unconscious has been widely influential, and derives from work by Freud in the late 19th and early 20th Century.The idea is situated in the wider set of notions developed by Freud called psychoanalysis.Central to Freud’s idea is the notion that “powerful unconscious drives, mostly sexual and aggressive… motivate human behaviour and put people in conflict with social reality” (Saiyadain 2003, p. 32).For Freud, the unconscious is that of which we are unaware, but which can manifest itself through thoughts and behaviours. He separated out three levels of consciousness:

The conscious (everything one is aware of)
The preconscious (things one is not aware of, but which could be brought to consciousness through effort of will)
The unconscious (that of which one is unaware, and which one is normally powerless to bring to conscious awareness)

The unconscious includes desires, buried memories, desires and needs. Individuals can be motivated by unconscious forces, which make themselves manifest through behaviour, thoughts, feelings and words. Freud believed therapeutic work could be done by uncovering these unconscious forces and making the individual aware of their deeper motivations through a process of psychoanalysis (McKenna 2000).

Freud suggested a number of ways in which the contents of the unconscious work to influence human behaviour. These include regression, repression, sublimation and projection. Regression is the phenomenon whereby people return to earlier behaviour patterns (for example a stutter), repression means the ways in which unpleasant emotions are blocked from conscious awareness, sublimation denotes the way in which impulses (perhaps aggressive) which are unacceptable to the conscious mind are channelled into another activity, for example devotion to work or sport, while projection means the mechanism whereby thoughts or feelings which are not acceptable to the conscious mind are attributed to someone else (finding them lazy, for example) (Saiyadain 2003).

Intuitively, and based on my experience in my placement, I feel that there is evidence for the existence of the unconscious. For example, I have seen adolescent children regress to an earlier stage, displaying bed wetting and thumb sucking for example, particularly at times of great stress. However, Freud’s ideas have been subject to an intense critique, particularly that there is a lack of empirical evidence for them (Hersen and Thomas 2006). Additionally, it has been pointed out that the idea of the unconscious lacks predictive power: although it can function as a good explanation of behaviour, it cannot indicate how people will behave in the future (Abbott 2001). I can see that these are valid criticisms: however, as the next sections show, I feel the concept of the unconscious and its mechanisms invaluable in understanding people better, which I feel is a necessary part of delivering the person-centred care that is a key part of social care in the 21st Century (Joseph Rowntree Foundation 2011).

3. The Unconscious and Organisational Life

As well as being widely influential (though much debated) in psychology generally, the concept of the unconscious and its mechanisms has been incorporated into theories of organisational life. The key element to the idea of the unconscious is the notion that “much of the rational and taken-for-granted reality of everyday life expresses preoccupations and concerns that lie beneath the reality of conscious awareness” (Morgan 1998, p. 186). It follows that organisational theories need to take account of the hidden dynamics which influence the workplace. In addition, it has been suggested that theorists of organisational behaviour have been influenced by unconscious forces such as repression. Morgan 1998, for example, suggests that Taylor’s model of ‘scientific’ and rational management might have been rooted in his puritan background with strong routines and work ethic. Morgan also suggests that the predominant bureaucracy of modern work places might be a function of repression. Worker’s reactions to these types of workplace will depend upon their own mechanisms of regression. In other workplaces, organisational culture can often by dominated by self-centred attempts at wrestling control from others, or the playing out of “a phallic-narcissistic ethos” (Morgan 1998, p. 192) within the workplace. Often, the workplace might reproduce the traditional patriarchal family, with a dominant style associated with ‘male’ qualities of aggression, ambition and rigid rules.

One unconscious mechanism which I was particularly aware of in my placement was projection.In this, workers deal with internal turmoil by attributing the key elements of what is bothering them to someone else rather than themselves. For example, in an organisation, poor results might be blamed by one group (managers) on ground-level staff, and vice-versa (Rashid 1983). Projection has been succinctly defined as the “attribution of one’s own attitudes and beliefs onto others” (Borkowski 2009, p. 56). In order to avoid feelings of guilt or excess anxiety, workers might see their co-workers as possessing the qualities they most dislike in themselves (Borkowski 2009). While it allows the person doing the projecting to protect their self-esteem, the mechanism whereby co-workers, for example, are blamed for putting a person in a bad mood, are damaging to organisational efficiency (Borkowski 2009). It can lead to stereotyping and, through this, to oppressive working methods. stereotyping is a way of organising experience by applying common traits to certain groups of people (the elderly, ethnic minorities, children). While it allows abstract thought to take place more easily, it can lead to the association of negative traits with particular groups. Projection seems to be at work in stereotyping, whereby a group is seen to possess negative characteristics not held by the person ascribing the characteristics. It has been shown that these mechanisms can lead to worse health and social care for certain groups seen as ‘the other’ (Borkowski 2009). One example is that people working with abused children can be marginalised and rendered invisible, as society as a whole does not want to admit that such abuse exists. Nurses are also often forced to bear the brunt of negative projections from service users and other professionals. In addition, social work in general often suffers, as its existence underlines the presence of vulnerable and needy people, mortality and other key issues. These all evoke deep and complex feelings in others, and workers in these professions often bear the weight of others negative expectations, “issues of dependency, aggression and sexuality” Yelloly and Henkel 1995, p. 195).

Within social work, it has been acknowledged that certain forms of practice can be oppressive, particularly to service users but also to other workers. Anti-oppressive practice works to overturn ways of working which marginalise, scapegoat and downplay the people who they work for, both on a personal and micro- level, and at a wider social level. While anti-oppressive practice covers a wide range of activities, becoming aware of the extent to which people are marginalised through unconscious mechanisms such as projection is one key part (Balloch and Hill 2007). Becoming aware of the extent to which negative characteristics are projected onto others, either individuals or groups, is a central step in moving away from oppression. Today, immigrant groups can find themselves scapegoated for the wider problems of society, for example, both by individuals and by political groups (Shulman 2008). Anti oppressive practice offers a way for projection, stereotyping and discrimination to be combated in the workplace, through an attitude of criticality and reflection upon situations in the workplace. The process of uncovering oppression can be likened to that of becoming aware of unconscious processes, as well as uncovering motivations which derive from unexamined unconscious attitudes and mechanisms (Heenan 2011).

4. Understanding the Unconscious and Improved User Outcomes

The ways in which the unconscious operates in the organisational context, the negative impact it can have, and the opportunities it presents for ultimately improving user outcomes is illustrated by my experience working in a children’s home.I have concentrated above on the phenomenon of projection, because this was the unconscious mechanism which most appeared to be in existence during my placement. One child with whom I worked, supporting to live independently after care, would frequently express the opinion that the women staff with whom she came into contact were ‘useless’, were over-emotional, and were not as effective as male staff. I used to find this frustrating, particularly as she was female herself, until I put her case into the context of her background. One of a family of girls, with whom her mother was unable to cope, she had internalised negative feelings about women, developed a androgenous, tomboy-ish appearance herself, and projected doubts and fears about herself onto female staff.

There are also discusses two related unconscious mechanisms (first identified by Melanie Klein), splitting and projective identification, both of which I experienced during my placement.Splitting often occurs in groups, and refers to the process whereby a situation is polarised and seen as ‘black’ and ‘white’, that is, with ‘good’ and ‘bad’ elements. It happens when people are unable to tolerate ambiguity (Zachar 2000). I saw this in group discussions between staff, when one manager who took a fairly strict line to discipline and adherence to regulations was demonised by staff informally after meetings. I felt (perhaps because I was an outsider) that although she might have expressed her ideas better, there was a great deal of sound advice in what she said. However, others seemed unable to see this, preferring to make her a ‘scapegoat’ for everything they disliked about the experience of working in the care home. I also saw this situation improve when a higher manager called a meeting in which we discussed communication styles used within the home.I also saw projective identification, where people unconsciously identify with another person or group, with one staff member, who seemed to project feelings of her own vulnerability (she had just gone through a difficult divorce) onto the female white children in our care. Her attitude towards this gender / ethnic group was markedly different, she would spend extra time with them, and buy small presents. I was present when this was noted by another staff member, who carefully suggested her experience might be leading to her favouritism. She took this suggestion very well, and her behaviour, I noticed, became fairer afterwards.

5. Conclusion

There are some problems with the notion of the unconscious, particularly its lack of predictive power and lack of empirical evidence. However, in terms of my placement in a children’s care home, I have found it a useful way of understanding why people – both staff and clients – behave in the way they do. It also seems to offer a useful tool for moving towards an anti-oppressive practice. In my experience, if people are made aware of the ways in which unconscious mechanisms operate, they are better able to see their oppressive actions, better able to understand why they are acting as they do, and as a consequence able to change the way they behave in a way which is beneficial to clients.

6. References

Abbott, T (2001) Social and personality development Routledge, UK

Balloch, S and Hill, M J (2007) Care, community and citizenship: research and practice in a changing policy context, The Policy Press, Bristol.

Baran, S J and Davis, D K (2011) Mass Communication Theory: Foundations, Ferment, and Future (6th edn.), Cengage Learning, Belmont, CA

Borkowski, N (2009) Organizational behavior, theory, and design in health care, Jones & Bartlett Learning, USA

Foster, A and Roberts, V Z (1998) Managing mental health in the community: chaos and containment, Routledge, UK

Heenan, D (2011) Social Work in Northern Ireland: Conflict and Change, The Policy Press, Bristol.

Joseph Rowntree Foundation (2011) ‘Transforming social care: sustaining person-centred support’, Joseph Rowntree Foundation, UK

McKenna, E F (2000) Business psychology and organisational behaviour (3rd edn.), Psychology Press, UK

Morgan, G (1998) Images of organization, Berrett-Koehler Publishers, California CA.

Nelson, D L and Campbell, J (2010) Organizational Behavior: Science, the Real World, and You (7th edn.), Cengage Learning, Belmont, CA.

Rashid, S A (1983) Organizational Behaviour, Taylor & Francis, UK

Saiyadain, M S (2003) Organisational Behaviour,m Tata McGraw-Hill Education, India.

Shulman, L (2008) The Skills of Helping Individuals, Families, Groups, and Communities (6th edn.), Cengage Learning, Belmont, CA.

Thomas, J C (2006) Personality and everyday functioning, John Wiley and Sons, Hoboken, NJ.

Yelloly, M and Henkel, M (1995) Learning and teaching in social work: towards reflective practice (2nd edn.), Jessica Kingsley Publishers, UK

Zachar, P (2000) Psychological Concepts and Biological Psychiatry: A Philosophical Analysis, John Benjamins Publishing Company, USA

Introduction

Commins (2006, p. 97) asserts that the teachings of Muhammad ibn Abd al-Wahhab have influenced the contemporary political and cultural environment in Saudi Arabia. This religious movement, commonly referred to as the Wahhabi movement started in central Arabia in the mid-18th Century and grew because of the preaching and scholarship of Muhammad ibn Abd al-Wahhab. According to Zayd (2006, p. 41), Muhammad ibn Abd al-Wahhab was a scholar of Islamic jurisprudence who received his education in Mesopotamia and Hijaz and then returned to Najd (central Arabia) to advocate for Islamic reforms. This paper explores how his teachings influenced the everyday life in Saudi Arabia.

Allen (2006, p.89) says that Muhammad ibn Abd al-Wahhab was concerned with the practices of the people of Najd, which he regarded as polytheistic and wanted them to stop the practices. He wanted reforms that would remove all practices that were added to Islam after the death of Mohammad. He was against practices like using votive and sacrificial offerings, veneration of caves, stones and trees, celebration of birthdays of prophets, praying to saints and making pilgrimages to special mosques and tombs. These were common practices in Najd and the people here regarded them as being in compliance with Islamic teachings. However, to Muhammad ibn Abd al-Wahhab they were polytheistic. He was concerned with these practices because he perceived them as being lax in terms of adherence to Islamic law. In addition to this, he was also concerned with the fact that the people were reluctant to perform religious devotions like disregard to obligatory prayers, not showing care to the widows and orphans, rampant adultery and failure to give women their fair share of inheritance. These practices formed the basis of his preaching as he was determined to make the people change their ways of life and start living in full compliance with Islamic laws.

Weston (2008, p. 11) asserts that his teachings revolved around the breaches of Islamic laws and emphasised the need to comply with all customary practices like jahiliya. He initially encountered opposition but eventually overcame it by forming an alliance with Muhammad ibn Saud, a local chieftain. This alliance ensured that his influence endured through difficult times because Muhammad ibn Saud was very powerful in southern Najd. Muhammad ibn Abd al-Wahhab and his descendants converted the alliance that was initially for political loyalty into religious obligation that had to be followed by everyone. In his teachings, he insisted that all Muslims must present an oath of allegiance (bayah) to Muslim leaders when alive so that they can get redemption when they die. He emphasised that Muslim leaders must be given unquestionable allegiance from the people as long as they are providing leadership that is in full conformity with Islamic laws. He held the perception that the purpose of the Muslim community was to be a living embodiment of Islamic laws (Hegghammer & Lacroix 2011, p. 64). The responsibility of ensuring that the community knows and conforms to the laws of God lay squarely on the legitimate rulers. Muhammad ibn Abd al-Wahhab and his followers then started a jihad targeting the backsliding Muslims in the region to ensure that there is total obedience to Muslim rulers and God. This was the beginning of religious intolerance in Saudi Arabia.
Fatah (2008, p. 77) claims that the key message in the teachings of Muhammad ibn Abd al-Wahhab was tawhid (oneness of God). Tawhid is very important in Saudi Arabia and it is emphasised by both state and religious leaders. It is for this reason that its adherents call the movement as the call for unity (ad dawa lil tawhid). He was against third party intercession and all prayer rituals because he considered them as leading to shirk. This is why he objected Sufi mysticism, celebrating the birthdays of prophets and Shia mourning ceremonies which were considered as religious festivals. As a consequence grave marking, building of tombs and any other shrines are forbidden in Wahhabism. However this is partly practised in Saudi Arabia because the shrine of Prophet Muhammad is in the country and Muslims go there to pay pilgrimage.
They only accept authority from the Sunna and Quran and disregard any reinterpretation of the two books on issues that were already settled by the previous jurists. They totally remain opposed to reinterpretation but give allowance for interpreting the areas not decided by the earlier jurists. Livingstone (2011, p. 50) suggests that they literally interpret the Sunna and Quran and aim towards enforcing parochial Najd practices. The religious and political leadership work collectively in ensuring that there is conformity in behaviour throughout the country.
Life in Saudi Arabia is guided by Wahhabism as the government remains committed to ensuring that there is full compliance with Islamic laws (Brym & Lie 2010, p. 31). In addition to this, the government has supported the Wahhabi literal interpretations of right and wrong behaviour. Prayer performance in a ritually correct and punctual manner is required of all men. Livingstone (2011, p.54) says that all the believers are forbidden from taking wine because literally, the Quran forbids it. They have extended this ban to include all intoxicating drinks and stimulants like tobacco. Both men and women are required to dress modestly in accordance with the Quran. These conservative regulations have direct influence on all aspects of life in Saudi Arabia. The leaders of Saudi Arabia support the conservative religious establishment and monitor closely the people who present potential threats to their regimes (Lacroix & Holoch 2011, p. 96).
In the Middle East, Saudi Arabia ranks as one of the most conservative and restrictive countries with those who do not subscribe to the Islamic religion barred from practicing their faith even in private (DeLong-Bas 2007, p. 66). It is this harsh, conservative and restrictive environment that has led to radicalisation of some people in Saudi Arabia as they have no tolerance to other religious faiths. In school the religious curriculum teaches students that there are two types of people; the first one is the Salafis (Wahhabis) who are the chosen ones and will go to heaven because they are the winners. The other group are Muslims, Jews, Christians and all other religions. These ones are either, enervators, or deniers of God (kafirs) or they put their gods next to God (mushrak). The Sunni Muslims are called enervators because they do things that are proscribed by Salafis like celebrating the birthday of Prophet Mohammed (Husain 2009, p. 15). All these groups of people are not accepted by the Saudi Arabians as Muslims and as such, they are supposed to be hated, persecuted and even killed. This is what the government is encouraging and has led the Saudi Arabians to be intolerant to any other dissenting views on religion because of the rapid radicalisation and fundamentalism (Allen 2006, p. 77).
This paper has shown that the teachings of Muhammad ibn Abd al-Wahhab influenced everyday life in Saudi Arabia. His teachings, which were originally intended to bring reforms to the Islamic faith, have gone to the extent of radicalising the people of Saudi Arabia. As the paper indicates, they have no tolerance for other religions. To them, the people of other religions should be hated, persecuted and even killed. This is what is fuelling fundamentalism and radicalism in Saudi Arabia and has already brought about extreme terrorists like Osama bin laden among others.

References

Allen, C. (2006). God’s terrorists: the Wahhabi cult and the hidden roots of modern Jihad. Cambridge: Da Capo Press.
Brym, R. J., & Lie, J. (2010). Sociology: Your compass for a new world, the brief edition. Belmont, California: Wadsworth Cengage Learning.
Commins, D. (2006). The Wahhabi mission and Saudi Arabia. London : Tauris.
DeLong-Bas, N. J. (2007). Wahhabi Islam: From revival and reform to global jihad. London: I.B. Tauris.
Fatah, T. (2008). Chasing a mirage: The tragic illusion of an Islamic state. Mississauga, Ont: John Wiley & Sons Canada.
Hegghammer, T., & Lacroix, S. (2011). The Meccan rebellion: The story of Juhayman al-?Utaybi revisited. Bristol, England: Amal Press.
Husain, E. (2009). The Islamist: Why I became an Islamic fundamentalist, what I saw inside, and why I left. New York, N.Y: Penguin Books USA.
Lacroix, S., & Holoch, G. (2011). Awakening Islam: The politics of religious dissent in contemporary Saudi Arabia. Cambridge, Mass: Harvard University Press.
Livingstone, D. (2011). Terrorism and the illuminati: A three-thousand-year history. Joshua Tree, CA: Progressive Press.
Weston, M. (2008). Prophets and princes: Saudi Arabia from Muhammad to the present. Hoboken, N.J: Wiley.
Zayd, N. A. (2006). Reformation of Islamic thought: A critical historical analysis. Amsterdam: Amsterdam Univ. Press.

As always, I am very grateful to al the people who made this book possible: my boys, Gabe, Seth, and Eli; my husband, Pancho; my parents, Stephen and Candy; my very supportive girlfriends Jen H., Jen L., Meghan, Nic, and Shel y; my ninja agent, Jodi

Reamer; my “baffy,” Shannon Hale; al my friends and mentors at Little, Brown, most especial y David Young, Asya Muchnick, Megan Tingley, Elizabeth Eulberg, Gail Doobinin, Andrew Smith, and Tina McIntyre; and, saving the best for last, my readers.

You’re the best audience anyone could have.

Thank you!

“She has surrendered,” the redhead explained.

“Surrendered?” Jane snapped.

I peeked up to see the dark-cloaks exchanging glances. The redhead had said that he’d never seen anyone surrender before. Maybe the dark-cloaks hadn’t, either.

“Carlisle gave her the option,” the redhead said. He seemed to be the spokesperson for the yel ow-eyes, though I thought Carlisle might be the leader.

“There are no options for those who break the rules,” Jane said, her voice dead again.

My bones felt like ice, but I didn’t feel panicked anymore. It al seemed so inevitable now.

Carlisle answered Jane in a soft voice. “That’s in your hands. As long as she was wil ing to halt her attack on us, I saw no need to destroy her. She was never taught.”

Though his words were neutral, I almost thought he was pleading for me. But, as he had said, my fate was not up to him.

“That is irrelevant,” Jane confirmed.

“As you wish.”

Jane was staring at Carlisle with an expression that was half confusion and half frustration. She shook her head, and her face was unreadable again.

“Aro hoped that we would get far enough west to see you, Carlisle,” she said. “He sends his regards.”

“I would appreciate it if you would convey mine to him,” he answered.

Jane smiled. “Of course.” Then she looked at me again, with the corners of her mouth stil slightly holding the smile. “It appears that you’ve done our work for us today… for the most part. Just out of professional curiosity, how many were there?

They left quite a wake of destruction in Seattle.”

She spoke of jobs and professionals. I was right, then, that it was her profession to punish. And if there were punishers, then there must be rules. Carlisle had said before, We follow their rules, and also, There is no law against creating vampires if you control them. Riley and my creator had been afraid but not exactly surprised by the arrival of the dark-cloaks, these Volturi. They knew about the laws, and they knew they were breaking them. Why hadn’t they told us? And there were more Volturi than just these four. Someone named Aro and probably many more. There must have been a lot for everyone to fear them so much. Carlisle answered Jane’s question. “Eighteen, including this one.”

There was a barely audible murmur among the four darkcloaks.

“Eighteen?” Jane repeated, a note of surprise in her voice. Our creator had never told Jane how many of us she’d created. Was Jane real y surprised, or just faking it?

“Al brand-new,” Carlisle said. “They were unskil ed.”

Unskil ed and uninformed, thanks to Riley. I was beginning to get a sense of how these older vampires viewed us. Newborn, Jasper had cal ed me. Like a baby.

“Al ?” Jane snapped. “Then who was their creator?”

As if they hadn’t already been introduced. This Jane was a bigger liar than Riley, and she was so much better at it than he was.

“Her name was Victoria,” the redhead answered.

How did he know that when even I didn’t? I remembered that Riley had said there was a mind reader in this group. Was that how they knew everything? Or was that another of Riley’s lies?

“Was?” Jane asked.

The redhead jerked his head toward the east like he was pointing. I looked up and saw a cloud of thick lilac smoke bil owing from the side of the mountain.

Was. I felt a similar kind of pleasure to what I’d felt imagining the big vampire shredding Raoul. Only much, much greater.

“This Victoria,” Jane asked slowly. “She was in addition to the eighteen here?”

“Yes,” the redhead confirmed. “She had only one other with her. He was not as young as this one here, but no older than a year.”

Riley. My fierce pleasure intensified. If – okay, when – I died today, at least I didn’t leave that loose thread. Diego had been avenged. I almost smiled.

“Twenty,” Jane breathed. Either this was more than she had expected, or she was a kil er actress. “Who dealt with the creator?”

“I did,” the redhead said coldly.

Whoever this vampire was, whether he kept a pet human or no, he was a friend of mine. Even if he were the one to kil me in the end, I would stil owe him.

Jane turned to stare at me with narrowed eyes.

“You there,” she snarled. “Your name.”

I was dead anyway, according to her. So why give this lying vampire anything she wanted? I just glared at her. Jane smiled at me, the bright, happy smile of an innocent child, and suddenly I was on fire. It was like I’d gone back in time to the worst night of my life. Fire was in every vein of my body, covering every inch of my skin, gnawing through the marrow of every bone. It felt like I was buried in the middle of my coven’s funeral bonfire, with the flames on every side. There wasn’t a single cel in my body that wasn’t blazing with the worst agony imaginable. I could barely hear myself scream over the pain in my ears.

“Your name,” Jane said again, and as she spoke the fire disappeared. Gone like that, as if I’d only been imagining it.

“Bree,” I said as fast as I could, stil gasping though the pain wasn’t there anymore.

Jane smiled again and the fire was everywhere. How much pain would it take before I would die of it? The screams didn’t even feel like they were coming from me anymore. Why wouldn’t someone rip my head off? Carlisle was kind enough for that, wasn’t he? Or whoever their mind reader was. Couldn’t he or she understand and make this stop?

“She’l tel you anything you want to know,” the redhead growled. “You don’t have to do that.”

The pain vanished again, like Jane had turned off a light switch. I found myself facedown on the ground, panting as if I needed air.

“Oh, I know,” I heard Jane say cheerful y. “Bree?”

I shuddered when she cal ed my name, but the pain didn’t start again.

“Is his story true?” she asked me. “Were there twenty of you?”

The words flew out of my mouth. “Nineteen or twenty, maybe more, I don’t know! Sara and the one whose name I don’t know got in a fight on the way….”

I waited for the pain to punish me for not having a better answer, but instead Jane spoke again.

“And this Victoria – did she create you?”

“I don’t know,” I admitted fearful y. “Riley never said her name. I didn’t see that night… it was so dark, and it hurt!” I flinched. “He didn’t want us to be able to think of her. He said that our thoughts weren’t safe.”

Jane shot a glance at the redhead, then looked at me again.

“Tel me about Riley,” Jane said. “Why did he bring you here?”

I recited Riley’s lies as quickly as I could. “Riley told us that we had to destroy the strange yel ow-eyes here. He said it would be easy. He said that the city was theirs, and they were coming to get us. He said once they were gone, al the blood would be ours. He gave us her scent.” I pointed in the human’s direction. “He said we would know that we had the right coven, because she would be with them. He said whoever got to her first could have her.”

“It looks like Riley was wrong about the easy part,” Jane said, a hint of teasing in her tone.

It seemed like Jane was pleased with my story. In a flash of insight, I understood that she was relieved Riley hadn’t told me or the others about her little visit to our creator. Victoria. This was the story she wanted the yel ow-eyes to know – the story that didn’t implicate Jane or the dark-cloaked Volturi. Wel, I could play along. Hopeful y the mind reader was already in the know.

I couldn’t physical y take revenge on this monster, but I could tel the yel ow-eyes everything with my thoughts. I hoped. I nodded, agreeing with Jane’s little joke, and sat up because I wanted the mind reader’s attention, whoever that was. I continued with the version of the story that any other member of my coven would have been able to give. I pretended I was Kevin. Dumb as a bag of rocks and total y ignorant.

“I don’t know what happened.” That part was true. The mess on the battlefield was stil a mystery. I’d never seen any of Kristie’s group. Did the secret howler vampires get them? I would keep that secret for the yel ow-eyes. “We split up, but the others never came. And Riley left us, and he didn’t come to help like he promised. And then it was so confusing, and everybody was in pieces.” I flinched at the memory of the torso I’d hurdled.

“I was afraid. I wanted to run away.” I nodded at Carlisle. “That one said they wouldn’t hurt me if I stopped fighting.”

This wasn’t betraying Carlisle in any way. He’d already told Jane as much.

“Ah, but that wasn’t his gift to offer, young one,” Jane said. She sounded like she was enjoying herself. “Broken rules demand a consequence.”

Stil pretending I was Kevin, I just stared at her as if I were too stupid to understand.

Jane looked at Carlisle. “Are you sure you got al of them?

The other half that split off?”

Carlisle nodded. “We split up, too.”

So it was the howlers that got Kristie. I hoped that, whatever else they were, the howlers were real y, real y terrifying. Kristie deserved that.

“I can’t deny that I’m impressed,” Jane said, sounding sincere, and I thought that this was probably the truth. Jane had been hopeful that Victoria’s army would do some damage here, and we’d clearly failed.

“Yes,” the three vampires behind Jane al agreed quietly.

“I’ve never seen a coven escape this magnitude of offensive intact,” Jane continued. “Do you know what was behind it? It seems like extreme behavior, considering the way you live here. And why was the girl the key?” Her eyes flicked to the human for just a moment.

“Victoria held a grudge against Bel a,” the redhead told her. So the strategy final y made sense. Riley just wanted the girl dead and didn’t care how many of us died to get it done. Jane laughed happily. “This one” – and she smiled at the human the way she’d smiled at me – “seems to bring out bizarrely strong reactions in our kind.”

Nothing happened to the girl. Maybe Jane didn’t want to hurt her. Or maybe her horrible talent only worked on vampires.

“Would you please not do that?” the redhead asked in a control ed but furious voice.

Jane laughed again. “Just checking. No harm done, apparently.”

I tried to keep my expression Kevin-ish and not betray my interest. So Jane couldn’t hurt this girl the way she’d hurt me, and this was not a normal thing for Jane. Though Jane was laughing about it, I could tel it was driving her crazy. Was this why the human girl was tolerated by the yel ow-eyes? But if she was special in some way, why didn’t they just change her into a vampire?

“Wel, it appears that there’s not much left for us to do,” Jane said, her voice a dead monotone again. “Odd. We’re not used to being rendered unnecessary. It’s too bad we missed the fight. It sounds like it would have been entertaining to watch.”

“Yes,” the redhead retorted. “And you were so close. It’s a shame you didn’t arrive just a half hour earlier. Perhaps then you could have fulfil ed your purpose here.”

I fought a smile. So the redhead was the mind reader, and he’d heard everything I’d wanted him to hear. Jane wasn’t getting away with anything.

Jane stared back at the mind reader with a blank expression. “Yes. Quite a pity how things turned out, isn’t it?”

The mind reader nodded, and I wondered what he was hearing in Jane’s head.

Jane turned her blank face to me now. There was nothing in her eyes, but I could feel that my time had run out. She’d gotten what she needed from me. She didn’t know that I’d also given the mind reader everything I could. And protected his coven’s secrets, too. I owed him that. He’d punished Riley and Victoria for me.

I glanced at him from the corner of my eye and thought, Thanks.

“Felix?” Jane said lazily.

“Wait,” the mind reader said loudly.

He turned to Carlisle and spoke quickly. “We could explain the rules to the young one. She doesn’t seem unwil ing to learn. She didn’t know what she was doing.”

“Of course,” Carlisle said eagerly, looking at Jane. “We would certainly be prepared to take responsibility for Bree.”

Jane’s face looked like she wasn’t sure if they were joking, but if they were joking, they were funnier than she’d given them credit for.

Me, I was touched to the core. These vampires were strangers, but they’d gone out on this dangerous limb for me. I already knew it wasn’t going to work, but stil .

“We don’t make exceptions,” Jane told them, amused. “And we don’t give second chances. It’s bad for our reputation.”

It was like she was discussing someone else. I didn’t care that she was talking about kil ing me. I knew the yel ow-eyes couldn’t stop her. She was the vampire police. But even though the vampire cops were dirty – real y dirty – at least the yel ow-eyes knew it now.

“Which reminds me…,” Jane went on, her eyes locking on the human girl again and her smile widening. “Caius wil be so interested to hear that you’re stil human, Bel a. Perhaps he’l decide to visit.”

Still human. So they were going to change the girl. I wondered what they were waiting for.

“The date is set,” said the little vampire with the short black hair and the clear voice. “Perhaps we’l come to visit you in a few months.”

Jane’s smile disappeared like someone had wiped it off. She shrugged without looking at the black-haired vampire, and I got the feeling that as much as she might have hated the human girl, she hated this smal vampire ten times as much. Jane turned back to Carlisle with the same vacant expression as before. “It was nice to meet you, Carlisle – I’d thought Aro was exaggerating. Wel, until we meet again…”

This would be it, then. I stil didn’t feel afraid. My only regret was that I couldn’t tel Fred more about al of this. He was going almost total y blind into this world ful of dangerous politics and dirty cops and secret covens. But Fred was smart and careful and talented. What could they do to him if they couldn’t even see him? Maybe the yel ow-eyes would meet Fred someday. Be nice to him, please, I thought at the mind reader.

“Take care of that, Felix,” Jane said indifferently, nodding at me. “I want to go home.”

“Don’t watch,” the redheaded mind reader whispered. I closed my eyes.

“Come with us. Don’t make one rash move or I will take you down.”

I felt angry again as he glared at me, and a smal part of me wanted to snarl and show my teeth, but I had a feeling he was looking for just that kind of excuse.

Jasper paused as if he’d just thought of something. “Close your eyes,” he commanded.

I hesitated. Had he decided to kil me after al ?

“Do it!”

I gritted my teeth and shut my eyes. I felt twice as helpless as I had before.

“Fol ow the sound of my voice and don’t open your eyes. You look, you lose, got it?”

I nodded, wondering what he didn’t want me to see. I felt some relief that he was bothering to protect a secret. There was no reason to do so if he was just going to kil me.

“This way.”

I walked slowly after him, careful to give him no excuses. He was considerate in the way he led, not walking me into any trees, at least. I could hear the way the sound changed when we were in the open; the feel of the wind was different, too, and the smel of my coven burning was stronger. I could feel the warmth of the sun on my face, and the insides of my eyelids were brighter as I sparkled.

He led me closer and closer to the muffled crackle of the flames, so close that I could feel the smoke brush my skin. I knew he could have kil ed me at any time, but the nearness of the fire stil made me nervous.

“Sit here. Eyes closed.”

The ground was warm from the sun and the fire. I kept very stil and tried to concentrate on looking harmless, but I could feel his glare on me, and it made me agitated. Though I was not mad at these vampires, who I truly believed had only been defending themselves, I felt the oddest stirrings of fury. It was almost outside myself, as if it were some leftover echo from the battle that had just taken place.

The anger didn’t make me stupid, though, because I was too sad – miserable to my core. Diego was aways in my mind, and I couldn’t help thinking about how he must have died. I was sure there was no way he would have voluntarily told Riley our secrets – secrets that had given me a reason to trust Riley just enough until it was too late. In my head, I saw Riley’s face again – that cold, smooth expression that had formed as he’d threatened to punish any of us who wouldn’t behave. I heard again his macabre and oddly detailed description – when I take you to her and hold you as she tears off your legs and then slowly, slowly burns off your fingers, ears, lips, tongue, and every other superfluous appendage one by one. I realized now that I’d been hearing the description of Diego’s death.

That night, I’d been sure that something had changed in Riley. Kil ing Diego was what had changed Riley, had hardened him. I believed only one thing that Riley had ever told me: he had valued Diego more than any of the rest of us. Had even been fond of him. And yet he’d watched our creator hurt him. No doubt he’d helped her. Kil ed Diego with her.

I wondered how much pain it would have taken to make me betray Diego. I imagined it would have taken quite a lot. And I was sure it had taken at least that much to make Diego betray me.

I felt sick. I wanted the image of Diego screaming in agony out of my head, but it wouldn’t leave.

And then there was screaming there in the field. My eyelids fluttered, but Jasper snarled furiously and I clenched them together at once. I’d seen nothing but heavy lavender smoke.

I heard shouting and a strange, savage howling. It was loud, and there was a lot of it. I couldn’t imagine how a face would have to contort to create such a noise, and the not knowing made the sound more frightening. These yel ow-eyed vampires were so different from the rest of us. Or different from me, I guess, since I was the only one left. Riley and our creator were long gone by now.

I heard names cal ed, Jacob, Leah, Sam. There were lots of distinct voices, though the howls continued. Of course Riley had lied to us about the number of vampires here, too. The sound of the howling tapered off until it was just one voice, one agonized, inhuman yowling that made me grit my teeth. I could see Diego’s face so clearly in my mind, and the sound was like him screaming.

I heard Carlisle talking over the other voices and the howling. He was begging to look at something. “Please let me take a look. Please let me help.” I didn’t hear anyone arguing with him, but for some reason his tone made it sound like he was losing the dispute.

And then the yowling reached a strident new pitch, and suddenly Carlisle was saying “thank you” in a fervent voice, and under the yowl there was the sound of a lot of movement by a lot of bodies. Many heavy footsteps coming closer.

I listened harder and heard something unexpected and impossible. Along with some heavy breathing – and I’ve never heard anyone in my coven breathe like that – there were dozens of deep thumping noises. Almost like… heartbeats. But definitely not human hearts. I knew that particular sound wel . I sniffed hard, but the wind was blowing from the other direction, and I could only smel the smoke.

Without a warning sound, something touched me, clapped down firmly on either side of my head.

My eyes started open in panic as I lurched up, straining to jerk free of this hold, and instantly met Jasper’s warning gaze about two inches from my face.

“Stop it,” he snapped, yanking me back down on my butt. I could only just hear him, and I realized that his hands were sealed tight against my head, covering my ears entirely.

“Close your eyes,” he instructed again, probably at a normal volume, but it was hushed for me.

I struggled to calm myself and shut my eyes again. There were things they didn’t want me to hear, either. I could live with that – if it meant I could live.

For a second I saw Fred’s face behind my eyelids. He had said he would wait for one day. I wondered if he would keep his word. I wished I could tel him the truth about the yel ow-eyes, and how much more there seemed to be that we didn’t know. This whole world that we real y knew nothing about. It would be interesting to explore that world. Particularly with someone who could make me invisible and safe.

But Diego was gone. He wouldn’t be coming to find Fred with me. That made imagining the future faintly repugnant. I could stil hear some of what was going on, but just the howling and a few voices. Whatever those weird thumping sounds had been, they were too muted now for me to examine them.

I did make out the words when, a few minutes later, Carlisle said, “You have to…” – his voice was too low for a second, and then – “… from here now. If we could help we would, but we cannot leave.”

There was a growl, but it was oddly unmenacing. The yowling became a low whine that disappeared slowly, as if it was moving away from me.

It was quiet for a few minutes. I heard some low voices, Carlisle and Esme among them, but also some I didn’t know. I wished I could smel something – the blindness combined with the muted sound left me straining for some source of sensory information. But al I could smel was the horribly sweet smoke. There was one voice, higher and clearer than the others, that I could hear most easily.

“Another five minutes,” I heard whoever it was say. I was sure it was a girl who was speaking. “And Bel a wil open her eyes in thirty-seven seconds. I wouldn’t doubt that she can hear us now.”

I tried to make sense of this. Was someone else being forced to keep her eyes shut, like me? Or did she think my name was Bel a? I hadn’t told anyone my name. I struggled again to smel something.

More mumbling. I thought that one voice sounded off – I couldn’t hear any ring to it at al . But I couldn’t be sure with Jasper’s hands so securely over my ears.

“Three minutes,” the high, clear voice said.

Jasper’s hands left my head.

“You’d better open your eyes now,” he told me from a few steps away. The way he said this frightened me. I looked around myself quickly, searching for the danger hinted at in his tone.

One whole field of my vision was obscured by the dark smoke. Close by, Jasper was frowning. His teeth were gritted together and he was looking at me with an expression that was almost… frightened. Not like he was scared of me, but like he was scared because of me. I remembered what he’d said before, about my putting them in danger with something cal ed a Volturi. I wondered what a Volturi was. I couldn’t imagine what this scarred-up, dangerous vampire would be afraid of. Behind Jasper, four vampires were spaced out in a loose line with their backs to me. One was Esme. With her were a tal blonde woman, a tiny black-haired girl, and a dark-haired male vampire so big that he was scary just to look at – the one I’d seen kil Kevin. For an instant I imagined that vampire getting a hold on Raoul. It was a strangely pleasant picture. There were three more vampires behind the big one. I couldn’t see exactly what they were doing with him in the way. Carlisle was kneeling on the ground, and next to him was a male vampire with dark red hair. Lying flat on the ground was another figure, but I couldn’t see much of that one, only jeans and smal brown boots. It was either a female or a young male. I wondered if they were putting the vampire back together. So eight yel ow-eyes total, plus al that howling before, whatever strange kind of vampire that had been; there had been at least eight more voices involved. Sixteen, maybe more. More than twice as many as Riley had told us to expect. I found myself fiercely hoping that those black-cloaked vampires would catch up to Riley, and that they would make him suffer.

The vampire on the ground started to get slowly to her feet – moving awkwardly, almost like she was some clumsy human. The breeze shifted, blowing the smoke across me and Jasper. For a moment, everything was invisible except for him. Though I was not as blind as before, I suddenly felt much more anxious, for some reason. It was like I could feel the anxiety bleeding out of the vampire next to me.

The light wind gusted back in the next second, and I could see and smel everything.

Jasper hissed at me furiously and shoved me out of my crouch and back onto the ground.

It was her – the human I’d been hunting just a few minutes ago. The scent my whole body had been focused toward. The sweet, wet scent of the most delicious blood I’d ever tracked. My mouth and throat felt like they were on fire. I tried wildly to hold on to my reason – to focus on the fact that Jasper was just waiting for me to jump up again so that he could kil me – but only part of me could do it. I felt like I was about to pul into two halves trying to keep myself here. The human named Bel a stared at me with stunned brown eyes. Looking at her made it worse. I could see the blood flushing through her thin skin. I tried to look anywhere else, but my eyes kept circling back to her.

The redhead spoke to her in a low voice. “She surrendered. That’s one I’ve never seen before. Only Carlisle would think of offering. Jasper doesn’t approve.”

Carlisle must have explained to that one when my ears were covered.

The vampire had both his arms around the human girl, and she had both hands pressed to his chest. Her throat was just inches from his mouth, but she didn’t look frightened of him at al . And he didn’t look like he was hunting. I had tried to wrap my head around the idea of a coven with a pet human, but this was not close to what I had imagined. If she’d been a vampire, I would have guessed that they were together.

“Is Jasper al right?” the human whispered.

“He’s fine. The venom stings,” the vampire said.

“He was bitten?” she asked, sounding shocked by the idea. Who was this girl? Why did the vampires al ow her to be with them? Why hadn’t they kil ed her yet? Why did she seem so comfortable with them, like they didn’t scare her? She seemed like she was a part of this world, and yet she didn’t understand its realities. Of course Jasper was bitten. He’d just fought – and destroyed – my entire coven. Did this girl even know what we were?

Ugh, the burn in my throat was impossible! I tried not to think about washing it away with her blood, but the wind was blowing her smel right in my face! It was too late to keep my head – I had scented the prey I was hunting, and nothing could change that now.

“He was trying to be everywhere at once,” the redhead told the human. “Trying to make sure Alice had nothing to do, actual y.” He shook his head as he looked at the tiny blackhaired girl. “Alice doesn’t need anyone’s help.”

The vampire named Alice shot a glare at Jasper.

“Overprotective fool,” she said in her clear soprano voice. Jasper met her stare with a half smile, seeming to forget for a second that I existed.

I could barely fight the instinct that wanted me to make use of his lapse and spring at the human girl. It would take less than an instant and then her warm blood – blood I could hear pumping through her heart – would quench the burn. She was so close –

The vampire with the dark red hair met my eyes with a fierce warning glare, and I knew I would die if I tried for the girl, but the agony in my throat made me feel like I would die if I didn’t. It hurt so much that I screamed out loud in frustration. Jasper snarled at me, and I tried to keep myself from moving, but it felt like the scent of her blood was a giant hand yanking me off the ground. I had never tried to stop myself from feeding once I had committed to a hunt. I dug my hands into the ground looking for something to hold on to but finding nothing. Jasper leaned into a crouch, and even knowing I was two seconds from death, I couldn’t focus my thirsty thoughts. And then Carlisle was right there, his hand on Jasper’s arm. He looked at me with kind, calm eyes. “Have you changed your mind, young one?” he asked me. “We don’t want to destroy you, but we wil if you can’t control yourself.”

“How can you stand it?” I asked him, almost begging. Wasn’t he burning, too? “I want her.” I stared at her, desperately wishing the distance between us was gone. My fingers raked uselessly through the rocky dirt.

“You must stand it,” Carlisle said solemnly. “You must exercise control. It is possible, and it is the only thing that wil save you now.”

If being able to tolerate the human the way these strange vampires did was my only hope for survival, then I was already doomed. I couldn’t stand the fire. And I was of two minds about survival anyway. I didn’t want to die, I didn’t want pain, but what was the point? Everyone else was dead. Diego had been dead for days.

His name was right on my lips. I almost whispered it aloud. Instead, I gripped my skul with both hands and tried to think about something that wouldn’t hurt. Not the girl, and not Diego. It didn’t work very wel .

“Shouldn’t we move away from her?” the human whispered roughly, breaking my concentration. My eyes snapped back to her. Her skin was so thin and soft. I could see the pulse in her neck.

“We have to stay here,” said the vampire she was clinging to. “They are coming to the north end of the clearing now.”

They? I glanced to the north, but there was nothing but smoke. Did he mean Riley and my creator? I felt a new thril of panic, fol owed by a little spasm of hope. There was no way she and Riley could stand against these vampires who had kil ed so many of us, was there? Even if the howly ones were gone, Jasper alone looked capable of dealing with the two of them. Or did he mean this mysterious Volturi?

The wind teased the girl’s scent across my face again, and my thoughts scattered. I glared at her thirstily. The girl met my stare, but her expression was so different from what it should have been. Though I could feel that my lips were curled back from my teeth, though I trembled with the effort to stop myself from springing at her, she did not look afraid of me. Instead she seemed fascinated. It almost looked like she wanted to speak to me – like she had a question she wanted me to answer.

Then Carlisle and Jasper began to back away from the fire – and me – closing ranks with the others and the human. They al were staring past me into the smoke, so whatever they were afraid of was closer to me than it was to them. I huddled tighter to the smoke in spite of the nearby flames. Should I make a run for it? Were they distracted enough that I could escape? Where would I go? To Fred? Off on my own? To find Riley and make him pay for what he’d done to Diego?

As I hesitated, mesmerized by that last idea, the moment passed. I heard movement to the north and knew I was sandwiched between the yel ow-eyes and whatever was coming.

“Hmm,” a dead voice said from behind the smoke. In that one syl able I knew exactly who it was, and if I hadn’t been frozen solid with mindless terror I would have bolted. It was the dark-cloaks.

What did this mean? Would a new battle begin now? I knew that the dark-cloaked vampires had wanted my creator to succeed in destroying these yel ow-eyes. My creator had clearly failed. Did that mean they would kil her? Or would they kil Carlisle and Esme and the rest here instead? If it had been my choice, I knew who I would want destroyed, and it wasn’t my captors.

The dark-cloaks ghosted through the vapor to face the yel ow-eyes. None of them looked in my direction. I held absolutely stil .

There were only four of them, like last time. But it didn’t make a difference that there were seven of the yel ow-eyes. I could tel that they were as wary of these dark-cloaks as Riley and my creator had been. There was something more to them than I could see, but I could definitely feel it. These were the punishers, and they didn’t lose.

“Welcome, Jane,” said the yel ow-eyed one who held the human.

They knew each other. But the redhead’s voice was not friendly – nor was it weak and eager to please like Riley’s had been, or furiously terrified like my creator’s. His voice was simply cold and polite and unsurprised. Were the dark-cloaks this Volturi, then?

The smal vampire who led the dark-cloaks – Jane, apparently – slowly scanned across the seven yel ow-eyes and the human, and then final y turned her head toward me. I glimpsed her face for the first time. She was younger than me, but much older, too, I guessed. Her eyes were the velvet color of dark red roses. Knowing it was too late to escape notice, I put my head down, covering it with my hands. Maybe if it were clear that I didn’t want to fight, Jane would treat me as Carlisle had. I didn’t feel much hope of that, though.

“I don’t understand.” Jane’s dead voice betrayed a hint of annoyance.

“I heard someone get hurt – Kristie needs me more than Raoul,” he explained quickly.

“Are you… leaving us?”

Riley’s face changed. It was like I could see his shifting tactics written on his features. His eyes widened, suddenly anxious.

“I’m worried, Bree. I told you that she was going to meet us, to help us, but I haven’t crossed her trail. Something’s wrong. I need to find her.”

“But there’s no way you can find her before Raoul gets to the yel ow-eyes,” I pointed out.

“I have to find out what’s going on.” He sounded genuinely desperate. “I need her. I wasn’t supposed to do this alone!”

“But the others…”

“Bree, I have to go find her! Now! There are enough of you to overwhelm the yel ow-eyes. I’l get back to you as soon as I can.”

He sounded so sincere. I hesitated, glancing back the way we had come. Fred would be halfway to Vancouver by now. Riley hadn’t even asked about him. Maybe Fred’s talent was stil in effect.

“Diego’s down there, Bree,” Riley said urgently. “He’l be part of the first attack. Didn’t you catch his scent back there?

Did you not get close enough?”

I shook my head, total y confused. “Diego was there?”

“He’s with Raoul by now. If you hurry, you can help him get out alive.”

We stared at each other for a long second, and then I looked south after Raoul’s path.

“Good girl,” Riley said. “I’l go find her and we’l be back to help clean up. You guys have got this! It might be over by the time you get there!”

He took off in a direction perpendicular to our original path. I clenched my teeth at how sure he seemed of his way. Lying to the end.

But it didn’t feel like I had a choice. I headed south in a flatout sprint again. I had to go get Diego. Drag him away if it came to that. We could catch up with Fred. Or take off on our own. We needed to run. I would tel Diego how Riley had lied. He would see that Riley had no intention of helping us fight the battle he’d set up. There was no reason to help him anymore. I found the human’s scent and then Raoul’s. I didn’t catch Diego’s. Was I going too fast? Or was the human’s scent just overpowering me? Half my head was absorbed in this strangely counterproductive hunt – sure, we would find the girl, but would we be ready to fight together when we did? No, we’d be clawing each other apart to get to her.

And then I heard the snarling and screaming and screeching explode from ahead and I knew the fight was happening and I was too late to beat Diego there. I only ran faster. Maybe I could stil save him.

I smel ed the smoke – the sweet, thick scent of vampires burning – carried back to me on the wind. The sound of mayhem was louder. Maybe it was almost done. Would I find our coven victorious and Diego waiting?

I dashed through a heavy fringe of smoke and found myself out of the forest in a huge grassy field. I leaped over a rock, only to realize in the instant I flew past it that it was a headless torso. My eyes raked the field. There were pieces of vampires everywhere, and a huge bonfire smoking purple into the sunny sky. Out from under the bil owing haze, I could see dazzling, glittering bodies darting and grappling as the sounds of vampires being torn apart went on and on.

I looked for one thing: Diego’s curly black hair. No one I could see had hair so dark. There was one huge vampire with brown hair that was almost black, but he was too big, and as I focused I watched him tear Kevin’s head off and pitch it into the fire before leaping on someone else’s back. Was that Jen?

There was another with straight black hair that was too smal to be Diego. That one was moving so fast I couldn’t tel if it was a boy or a girl.

I scanned quickly again, feeling horribly exposed. I took in the faces. There weren’t nearly enough vampires here, even counting those that were down. I didn’t see any of Kristie’s group. There must have been a lot of vampires burned already. Most of the vampires stil standing were strangers. A blond vampire glanced at me, meeting my gaze, and his eyes flashed gold in the sunlight.

We were losing. Bad.

I started backing toward the trees, not moving fast enough because I was stil looking for Diego. He wasn’t here. There was no sign he had ever been here. No trace of his scent, though I could distinguish the smel s of most of Raoul’s team and many strangers. I had made myself look at the pieces, too. None of them belonged to Diego. I would have recognized even a finger.

I turned and real y ran for the trees, suddenly positive that Diego’s presence here was just another of Riley’s lies. And if Diego wasn’t here, then he was already dead. This fel into place for me so easily that I thought I must have known the truth for a while. Since the moment that Diego had not fol owed Riley through the basement door. He’d already been gone.

I was a few feet into the trees when a force like a wrecking bal hit me from behind and threw me to the ground. An arm slipped under my chin.

“Please!” I sobbed. And I meant please kill me fast. The arm hesitated. I didn’t fight back, though my instincts were urging me to bite and claw and rip the enemy apart. The saner part of me knew that wasn’t going to work. Riley had lied about these weak, older vampires, too, and we’d never had a chance. But even if I’d had a way to beat this one, I wouldn’t have been able to move. Diego was gone, and that glaring fact kil ed the fight in me.

Suddenly I was airborne. I crashed into a tree and crumpled to the ground. I should have tried to run, but Diego was dead. I couldn’t get around that.

The blond vampire from the clearing was staring intently at me, his body ready to spring. He looked very capable, much more experienced than Riley. But he wasn’t lunging at me. He wasn’t crazed like Raoul or Kristie. He was total y in control.

“Please,” I said again, wanting him to get this over with. “I don’t want to fight.”

Though he stil held himself ready, his face changed. He looked at me in a way I didn’t total y get. There was a lot of knowledge in that face, and something else. Empathy? Pity, at least.

“Neither do I, child,” he said in a calm, kind voice. “We are only defending ourselves.”

There was such honesty in his odd yel ow eyes that it made me wonder how I had ever believed any of Riley’s stories. I felt… guilty. Maybe this coven had never planned to attack us in Seattle. How could I trust any part of what I’d been told?

“We didn’t know,” I explained, somehow ashamed. “Riley lied. I’m sorry.”

He listened for a moment, and I realized that the battlefield was quiet. It was over.

If I’d been in any doubt over who the winner was, that doubt was gone when, a second later, a female vampire with wavy brown hair and yel ow eyes hurried to his side.

“Carlisle?” she asked in a confused voice, staring at me.

“She doesn’t want to fight,” he told her.

The woman touched his arm. He was stil tensed to spring.

“She’s so frightened, Carlisle. Couldn’t we…”

The blond, Carlisle, glanced back at her, and then he straightened up a little, though I could see he was stil wary.

“We have no wish to harm you,” the woman said to me. She had a soft, soothing voice. “We didn’t want to fight any of you.”

“I’m sorry,” I whispered again.

I couldn’t make sense of the mess in my head. Diego was dead, and that was the main thing, the devastating thing. Other than that, the fight was over, my coven had lost and my enemies had won. But my dead coven was ful of people who would have loved to watch me burn, and my enemies were speaking to me kindly when they had no reason to. Moreover, I felt safer with these two strangers than I’d ever felt with Raoul and Kristie. I was relieved that Raoul and Kristie were dead. It was so confusing.

“Child,” Carlisle said, “wil you surrender to us? If you do not try to harm us, we promise we wil not harm you.”

And I believed him.

“Yes,” I whispered. “Yes, I surrender. I don’t want to hurt anybody.”

He held out his hand encouragingly. “Come, child. Let our family regroup for a moment, then we’l have some questions for you. If you answer honestly, you have nothing to fear.”

I got up slowly, making no movements that could be considered threatening.

“Carlisle?” a male voice cal ed.

And then another yel ow-eyed vampire joined us. Any sort of safety I’d felt with these strangers vanished as soon as I saw him.

He was blond, like the first, but tal er and leaner. His skin was absolutely covered in scars, spaced most thickly together on his neck and jaw. A few smal marks on his arm were fresh, but the rest were not from the brawl today. He had been in more fights than I could have imagined, and he’d never lost. His tawny eyes blazed and his stance exuded the barely contained violence of an angry lion.

As soon as he saw me he coiled to spring.

“Jasper!” Carlisle warned.

Jasper pul ed up short and stared at Carlisle with wide eyes. “What’s going on?”

“She doesn’t want to fight. She’s surrendered.”

The scarred vampire’s brow clouded, and suddenly I felt an unexpected surge of frustration, though I had no idea what I was frustrated with.

“Carlisle, I…” He hesitated, then continued, “I’m sorry, but that’s not possible. We can’t have any of these newborns associated with us when the Volturi come. Do you realize the danger that would put us in?”

I didn’t understand exactly what he was saying, but I got enough. He wanted to kil me.

“Jasper, she’s only a child,” the woman protested. “We can’t just murder her in cold blood!”

It was strange to hear her speak like we both were people, like murder was a bad thing. An avoidable thing.

“It’s our family on the line here, Esme. We can’t afford to have them think we broke this rule.”

The woman, Esme, walked between me and the one who wanted to kil me. Incomprehensibly, she turned her back to me.

“No. I won’t stand for it.”

Carlisle shot me an anxious glance. I could see that he cared a lot for this woman. I would have looked the same way at anyone behind Diego’s back. I tried to appear as docile as I felt.

“Jasper, I think we have to take the chance,” he said slowly.

“We are not the Volturi. We fol ow their rules, but we do not take lives lightly. We wil explain.”

“They might think we created our own newborns in defense.”

“But we didn’t. And even had we, there was no indiscretion here, only in Seattle. There is no law against creating vampires if you control them.”

“This is too dangerous.”

Carlisle touched Jasper’s shoulder tentatively. “Jasper. We cannot kil this child.”

Jasper glowered at the man with the kind eyes, and I was suddenly angry. Surely he wouldn’t hurt this gentle vampire or the woman he loved. Then Jasper sighed, and I knew it was okay. My anger evaporated.

“I don’t like this,” he said, but he was calmer. “At least let me take charge of her. You two don’t know how to deal with someone who’s been running wild so long.”

“Of course, Jasper,” the woman said. “But be kind.”

Jasper rol ed his eyes. “We need to be with the others. Alice said we don’t have long.”

Carlisle nodded. He held his hand out to Esme, and they headed past Jasper back toward the open field.

“You there,” Jasper said to me, his face a glower again.

Introduction

This proposal outlines the following research question: in what ways, positive or negative, will the World Expo 2020 affect Dubai, the surrounding region, and the world in generalThis is an interesting topic for two primary reasons. The first is the personal workplace experience of the author, which involved a position at Dubai Media Incorporated (Dubai TV) conducting analysis about current affairs in the UAE region. The second is the fact that this is a landmark moment in the history of Dubai, the UAE, and the Middle in general, as it is the first time that an international exposition has been held in the region. It is possible that it will lead to the development of new forms of culture; the old may be reformulated and developed in unique ways, but it may also be fused with ideas and institutions from abroad to create novel cultural hybrids.
This idea of bringing regions of the Middle East together with the rest of the world was explicitly supported by Sheikh Mohammed bin Rashid Al Maktoum, Dubai’s leader, who argued for the importance of ‘a renewed vision of progress and development based on a shared purpose and commitment’ (Expo 2020 Dubai, UAE, 2013). The possibility that the Expo 2020 will be a crucible for interacting creative forces across the world is, moreover, encapsulated in Dubai’s chosen theme: ‘Connecting Minds, Creating the Future’ (Big News Network, 2013).

Research questions

This research will aim to answer the following questions:
What factors are likely to contribute to the success or failure of the World Expo 2020?

What are the social, economic, and cultural changes that Dubai is a likely to experience?

How will be Dubai’s future in the global stage change as a result of this event?

How might Dubai use the World Expo 2020 as a marketing tool?

How might Dubai use the symbolic economy to aid its cultural and urban regeneration and shape its new urban identity?

Will Expo 2020 commentary and press show Dubai in a positive or negative light?

Literature review

Due to the very recent nature of the announcement, there is almost no literature dealing directly with the relationship between Dubai and the Expo 2020. However, there has been considerable commentary in the form of political and economic punditry, much of which is academic. Piers Schreiber, Vice President of Corporate Communications & Public Affairs at the Jumeirah Group, claimed that ‘the Expo will create up to 270,000 jobs in the region, bringing great economic and social benefits’ (cited in Wilson, 2013). Among these are an injection of roughly ˆ17.7 billion into the economy and a migration of talent from abroad (Wilson, 2013). These estimations are supported by the forecasting group Oxford Economics, which claims that the event will contribute nearly $40 billion to Dubai’s GDP and create 277,000 new jobs over the next seven years (Big News Network, 2013). A similar argument is put forward by Rose and Spiegel (2009), whose work suggests that ‘mega events’ lead to a substantial increase in trade (approx. 30%); however, they also show that ‘unsuccessful bids to host the Olympics have a similar positive impact on exports…trade is attributable to the signal a country sends when bidding to host the games, rather than the act of actually holding a mega-event’ (p1).
Although Sheik Mohammed has claimed that the “Dubai Expo 2020 will breathe new life into the ancient role of the Middle East as a melting pot for cultures and creativity” (Big News Network, 2013), the goal of cultural diversity has been questioned due to the strong emphasis on boosting an ‘Islamic economy’, which suggests continuity more than change (Wilson, 2013).
Based on comparisons with other ‘mega events’, it is often argued that the effects of the Expo 2020 are likely to be negative for Dubai. Rose and Spiegel (2009), for example, stress that much of the evidence for the benefits of mega events is commissioned by groups with biasing agendas (e.g., Humphreys and Plummer, 1995; Fuller and Clinch, 2000, both cited in Rose and Spiegel, 2009). The same is argued by Nitsch and Wendland (2013), who also point to the large initial investment in facilities and infrastructure associated with mega events, which can place a considerable burden on the local or national economy; there tends also to be a dramatic and unpredictable effect on property prices. The conclusion of Nitsch and Wendland (2013) is that mega events tend to have an overwhelmingly negative effect on population growth (i.e., a population decline), as measured relative to a control group.
However, Nitsch and Wendland (2013), and Rose and Spiegel (2009), point to the difficulty of estimating the impact of major events. Problems quantifying the effects, especially on phenomena such as labour markets, are often exacerbated by the fact that many studies are commissioned ex ante by biased groups. Moreover, in conducting analyses such as this, it is difficult to find an adequate sample size due to the infrequency of mega events. Then there are problems with the intangibility of cultural and social spillover effects, as well as the economic multiplier (Rose and Spiegel, 2009).

Methodology

The effects of the Expo 2020 are best assessed using a variety of methodological approaches, employing both quantitative and qualitative methods. From the quantitative side there will be content analysis-case studies and statistical analyses. From the qualitative, there will be surveys, questionnaires, and interviews. In terms of research philosophy (or methodology, strictly speaking), this research will take both an objectivist and a subjectivist approach (Crotty, 1998).
It would be advantageous to use what Nitsch and Wendland (2013: 4) call a ‘difference-in-differences methodology’. This draws ‘before and after’ comparisons, and in this case would entail looking at the effect of former Expos on host nations and cities and extrapolating about the probable effects on Dubai.

Bibliography

Crotty, M. (1998) The foundation of Social Research: Meaning and Perspective in Research Progress. Sage Publications: London
Big News Network (Nov 2013) Dubai wins right to host Expo 2020 http://www.bignewsnetwork.com/index.php/sid/218715287/scat/3a8a80d6f705f8cc/ht/Dubai-wins-right-to-host-Expo-2020 [Retrieved 03/02/2014].
Nitsch, V. and Wendland, N. (2013) The IOC’s Midas Touch: Summer Olympics and City Growth, CESIFO WORKING PAPER NO. 4378, Centre for Economic Studies & Ifo Institute.
Expo 2020 Dubai, UAE (2013) Our Bid http://expo2020dubai.ae/en/our_bid [Retrieved 03/02/2014]
Rose, A. K. and Spiegel, M. M. (2009) The Olympic Effect, NBER Working Paper No. 14854, The National Bureau of Economic Research http://www.nber.org/papers/w14854 [Retrieved 03/02/2014].

Wilson, J. A. J. (Dec 2013) Global Islamic Economy Summit and World Expo 2020 boost Dubai’s Halal credentials, The Huffington Post http://www.huffingtonpost.co.uk/jonathan-aj-wilson/global-islamic-economy_b_4366436.html [Retrieved 03/02/2014].

Fred raised an eyebrow and relaxed just slightly. I glanced behind us. What had Riley been looking at?

Nothing had changed – just some family pictures of dead people, a smal mirror, and a cuckoo clock. Hmm. Was he checking the time? Maybe our creator had given him a deadline, too.

“‘Kay, guys, I’m going out,” Riley said. “You don’t have to be afraid today, I promise.”

The light burst into the basement through the open door, magnified – as only I knew – by Riley’s skin. I could see the bright reflections dance on the wal .

Hissing and snarling, my coven backed into the corner opposite from Fred’s. Kristie was in the very back. It looked like she was trying to use her gang as a kind of shield.

“Relax, everybody,” Riley cal ed down to us. “I am absolutely fine. No pain, no burn. Come and see. C’mon!”

No one moved closer to the door. Fred was crouched against the wal beside me, eyeing the light with panic. I waved my hand a tiny bit to get his attention. He looked up at me and measured my total calm for a second. Slowly he straightened up next to me. I smiled encouragingly.

Everyone else was waiting for the burn to start. I wondered if I had looked that sil y to Diego.

“You know,” Riley mused from above, “I’m curious to see who is the bravest one of you. I have a good idea who the first person through that door is going to be, but I’ve been wrong before.”

I rol ed my eyes. Subtle, Riley.

But of course it worked. Raoul started inching his way toward the stairs almost immediately. For once, Kristie was in no hurry to compete with him for Riley’s approval. Raoul snapped his fingers at Kevin, and both he and the Spider-Man kid reluctantly moved to flank him.

“You can hear me. You know I’m not fried. Don’t be a bunch of babies! You’re vampires. Act like it.”

Stil, Raoul and his buddies couldn’t get farther than the foot of the stairs. None of the others moved. After a few minutes, Riley came back. In the indirect light from the front door, he shimmered just a tiny bit in the doorway.

“Look at me – I’m fine. Seriously! I’m embarrassed for you. C’mere, Raoul!”

In the end, Riley had to grab Kevin – Raoul ducked out of the way as soon as he could see what Riley was thinking – and drag him upstairs by force. I saw the moment when they made it into the sun, when the light brightened from their reflections.

“Tel them, Kevin,” Riley ordered.

“I’m okay, Raoul!” Kevin cal ed down. “Whoa. I’m al … shiny. This is crazy!” He laughed.

“Wel done, Kevin,” Riley said loudly.

That did it for Raoul. He gritted his teeth and marched up the stairs. He didn’t move fast, but soon he was up there sparkling and laughing with Kevin.

Even from then on, the process took longer than I would have predicted. It was stil a one-by-one thing. Riley got impatient. It was more threats than encouragement now. Fred shot me a look that said, You knew this?

Yes, I mouthed.

He nodded and started up the stairs. There were stil about ten people, mostly Kristie’s group, huddled against the wal . I went with Fred. Better to come out right in the middle. Let Riley read into that what he would.

We could see the shining, disco-bal vampires in the front yard, staring at their hands and each other’s faces with rapt expressions. Fred moved into the light without slowing, which I thought was pretty brave, al things considered. Kristie was a better example of how wel Riley had indoctrinated us. She clung to what she knew regardless of the evidence in front of her.

Fred and I stood a little space from the others. He examined himself careful y, then looked me over, then stared at the others. It struck me that Fred, though real y quiet, was very observant and almost scientific in the way he examined evidence. He’d been evaluating Riley’s words and actions al along. How much had he figured out?

Riley had to force Kristie up the stairs, and her gang came with her. Final y we al were out in the sun, most people enjoying how very pretty they were. Riley rounded everyone up for one more quick practice session – mostly, I thought, to get them to focus again. It took them a minute, but everyone started to realize that this was it, and they got quieter and more fierce. I could see that the idea of a real fight – of being not only al owed but encouraged to rip and burn – was almost as exciting as hunting. It appealed to people like Raoul and Jen and Sara. Riley focused on a strategy he’d been trying to dril into them for the last few days – once we’d pinpointed the yel oweyes’ scent, we were going to divide in two and flank them. Raoul would charge them head-on while Kristie attacked from the side. The plan suited both their styles, though I wasn’t sure if they were going to be able to fol ow this strategy in the heat of the hunt.

When Riley cal ed everyone together after an hour of practice, Fred immediately started walking backward toward the north; Riley had the others facing south. I stayed close, though I had no idea what he was doing. Fred stopped when we were a good hundred yards away, in the shade of the spruce trees on the fringe of the forest. No one watched us move away. Fred was eyeing Riley, as if waiting to see if he would notice our retreat.

Riley began speaking. “We leave now. You’re strong and you’re ready. And you’re thirsty for it, aren’t you? You can feel the burn. You’re ready for dessert.”

He was right. Al that blood hadn’t slowed the return of the thirst at al . In fact, I wasn’t sure, but I thought it might be coming back faster and harder than usual. Maybe overfeeding was counterproductive in some ways.

“The yel ow-eyes are coming in slowly from the south, feeding along the way, trying to get stronger,” Riley said. “She’s been monitoring them, so I know where to find them. She’s going to meet us there, with Diego” – he cast a significant glance toward where I’d just been standing, and then a quick frown that disappeared just as quickly – “and we wil hit them like a tsunami. We wil overwhelm them easily. And then we wil celebrate.” He smiled. “Someone’s going to get a jump on the celebration. Raoul – give me that.” Riley held out his hand imperiously. Raoul reluctantly tossed him the bag with the shirt. It seemed like Raoul was trying to lay claim to the girl by hogging her scent.

“Take another whiff, everybody. Let’s get focused!”

Focused on the girl? Or the fight?

Riley himself walked the shirt around this time, almost like he wanted to make sure everyone was thirsty. And I could see from the reactions that, like me, the burn was back for them al . The scent of the shirt made them scowl and snarl. It wasn’t necessary to give us the scent again; we forgot nothing. So this was probably just a test. Just thinking about the girl’s scent had venom pooling in my mouth.

“Are you with me?” Riley bel owed.

Everyone screamed his or her assent.

“Let’s take them down, kids!”

It was like the barracuda again, only on land this time. Fred didn’t move, so I stayed with him, though I knew I was wasting time I needed. If I were going to get to Diego and pul him away before the fighting could start, I would need to be near the front of the attack. I looked after them anxiously. I was stil younger than most of them – faster.

“Riley won’t be able to think of me for about twenty minutes or so,” Fred told me, his voice casual and familiar, like we’d had a mil ion conversations in the past. “I’ve been gauging the time. Even a good distance away, he’l feel sick if he tries to remember me.”

“Real y? That’s cool.”

Fred smiled. “I’ve been practicing, keeping track of the effects. I can make myself total y invisible now. No one can look at me if I don’t want them to.”

“I’ve noticed,” I said, then paused and guessed, “You’re not going?”

Fred shook his head. “Of course not. It’s obvious we’re not being told what we need to know. I’m not going to be Riley’s pawn.”

So Fred had figured it out on his own.

“I was going to take off sooner, but then I wanted to talk to you before I left, and there hasn’t been a chance til now.”

“I wanted to talk to you, too,” I said. “I thought you should know that Riley’s been lying about the sun. This four-day thing is a total crock. I think Shel y and Steve and the others figured it out, too. And there’s a lot more politics going on with this fight than he’s told us. More than one set of enemies.” I said it fast, feeling with terrible urgency the movement of the sun, the time passing. I had to get to Diego.

“I’m not surprised,” Fred said calmly. “And I’m out. I’m going to explore on my own, see the world. Or I was going on my own, but then I thought maybe you might want to come, too. You’d be pretty safe with me. No one wil be able to fol ow us.”

I hesitated for a second. The idea of safety was hard to resist in that exact moment.

“I’ve got to get Diego,” I said, shaking my head. He nodded thoughtful y. “I get it. You know, if you’re wil ing to vouch for him, you can bring him along. Seems like sometimes numbers come in handy.”

“Yes,” I agreed fervently, remembering how vulnerable I’d felt in the tree alone with Diego as the four cloaks had advanced. He raised an eyebrow at my tone.

“Riley is lying about at least one more important thing,” I explained. “Be careful. We aren’t supposed to let humans know about us. There are some kind of freaky vampires who stop covens when they get too obvious. I’ve seen them, and you don’t want them to find you. Just keep out of sight in the day, and hunt smart.” I looked south anxiously. “I have to hurry!”

He was processing my revelations solemnly. “Okay. Catch up to me if you want. I’d like to hear more. I’l wait for you in Vancouver for one day. I know the city. I’l leave you a trail in…”

He thought for a second and then chuckled once. “Riley Park. You can fol ow it to me. But after twenty-four hours I’m taking off.”

“I’l get Diego and catch up to you.”

“Good luck, Bree.”

“Thanks, Fred! Good luck to you, too. I’l see you!” I was already running.

“I hope so,” I heard him say behind me.

I sprinted after the scent of the others, flying along the ground faster than I’d ever run before. I was lucky that they must have paused for something – for Riley to yel at them, I was guessing – because I caught them sooner than I should have. Or maybe Riley had remembered Fred and stopped to look for us. They were running at a steady pace when I reached them, semidisciplined like last night. I tried to slide into the group without drawing attention, but I saw Riley’s head flip around once to scan those trailing behind. His eyes zeroed in on me, and then he started running faster. Did he assume Fred was with me?

Riley would never see Fred again.

It wasn’t five minutes later when everything changed. Raoul caught the scent. With a wild growl he was off. Riley had us so worked up that it took only the tiniest spark to set off an explosion. The others near Raoul had the scent, too, and then everyone went crazy. Riley’s harping on this human had overshadowed the rest of his instructions. We were hunters, not an army. There was no team. It was a race for blood. Even though I knew there were a lot of lies in the story, I couldn’t total y resist the scent. Running at the back of the pack, I had to cross it. Fresh. Strong. The human had been here recently, and she smel ed so sweet. I was strong with al the blood we’d drunk last night, but it didn’t matter. I was thirsty. It burned.

I ran after the others, trying to keep my head clear. It was al I could do to hold back a little, to stay behind the others. The closest person to me was Riley. He was… holding back, too?

He shouted orders, mostly the same thing repeated.

“Kristie, go around! Move around! Split off! Kristie, Jen! Break off! ” His whole plan of the two-pronged ambush was selfdestructing as we watched. Riley sped up to the main group and grabbed Sara’s shoulder. She snapped at him as he hurled her to the left. “Go around!” he shouted. He caught the blond kid whose name I’d never figured out and shoved him into Sara, who clearly wasn’t happy with that. Kristie came out of the hunting focus long enough to realize she was supposed to be moving strategical y. She gave one fierce gaze after Raoul and then started screeching at her team.

“This way! Faster! We’l beat them around and get to her first! C’mon!”

“I’m spear point with Raoul!” Riley shouted at her, turning away.

I hesitated, stil running forward. I didn’t want to be part of any “spear point,” but Kristie’s team was already turning on each other. Sara had the blond kid in a headlock. The sound of his head tearing off made my decision for me. I sprinted after Riley, wondering if Sara would pause to burn the boy who liked to play Spider-Man.

I caught up enough to see Riley ahead and fol owed at a distance until he got to Raoul’s team. The scent made it hard to keep my mind on the things that mattered.

“Raoul!” Riley yel ed.

Raoul grunted, not turning. He was total y absorbed by the sweet scent.

“I’ve got to help Kristie! I’l meet you there! Keep your focus!”

I jerked to a stop, frozen with uncertainty.

Raoul kept on, not showing any response to Riley’s words. Riley slowed to a jog, then a walk. I should have moved, but he probably would have heard me try to hide. He turned, a smile on his face, and saw me.

“Bree. I thought you were with Kristie.”

I didn’t respond.

“Tonight you get a taste of what our world wil be like when our competition is out of the picture. Fol ow me!”

Riley bounded away; Raoul and his team were right on his heels. Kristie’s group started shoving and clawing right through the middle of them to get to the front.

“Don’t make me change my mind!” Riley bel owed from the trees ahead. “You can al go thirsty. I don’t care!”

Kristie barked an order and her group sul enly fel behind Raoul’s. Fred and I waited until the last of them was out of sight. Then Fred did one of those little ladies first sweeps with his arm. It didn’t feel like he was afraid to have me at his back, just that he was being polite. I started running after the army. The others were already long gone, but it was nothing to fol ow their smel . Fred and I ran in companionable silence. I wondered what he was thinking. Maybe he was only thirsty. I was burning, so he probably was, too.

We caught up to the others after about five minutes, but kept our distance. The army was moving in amazing quiet. They were focused, and more… disciplined. I kind of wished that Riley had started the training sooner. It was easier to be around this group.

We crossed over an empty two-lane freeway, another strip of forest, and then we were on a beach. The water was smooth, and we’d gone almost due north, so this must have been the strait. We hadn’t passed near any residences, and I was sure that was on purpose. Thirsty and on edge, it wouldn’t take too much to dissolve this smal measure of organization into a screaming free-for-al .

We’d never hunted al together before, and I was pretty sure that it was not a good idea now. I remembered Kevin and the Spider-Man kid fighting over the woman in the car that first night I’d talked to Diego. Riley had better have a whole lot of bodies for us or people were going to start tearing each other up to get the most blood.

Riley paused at the water’s edge.

“Don’t hold back,” he told us. “I want you wel fed and strong – at your peak. Now… let’s go have some fun.”

He dove smoothly into the surf. The others were growling excitedly as they submerged, too. Fred and I fol owed more closely than before because we couldn’t fol ow their scent under water. But I could feel that Fred was hesitant – ready to bolt if this was something other than an al -you-can-eat smorgasbord. It seemed like he didn’t trust Riley any more than I did. We didn’t swim long, and then we saw the others kicking upward. Fred and I surfaced last, and Riley started talking as soon as our heads were out of the water, like he’d been waiting for us. He must have been more aware of Fred than the others were.

“There she is,” he said, waving toward a large ferry chugging south, probably making the last commuter run of the night down from Canada. “Give me a minute. When the power goes out, she’s al yours.”

There was an excited murmur. Someone giggled. Riley was off like a shot, and seconds later we saw him fly up the side of the big boat. He headed straight for the control tower on top of the ship. Silencing the radio was my bet. He could say al he wanted about these enemies being our reason for caution, but I was sure there was more to it than that. Humans weren’t supposed to know about vampires. At least, not for very long. Just long enough for us to kil them.

Riley kicked a big plate-glass window out of his way and disappeared into the tower. Five seconds later, the lights went out.

I realized Raoul was already gone. He must have submerged so we wouldn’t hear him swimming after Riley. Everyone else took off, and the water churned as if an enormous school of barracuda were attacking.

Fred and I swam at a relatively leisurely pace behind them. In a funny way, it was like we were some old married couple. We never talked, but we stil did things at exactly the same time. We got to the boat about three seconds later, and already the air was ful of shrieks and the warm scent of blood. The smel made me realize exactly how thirsty I was, but that was the last thing I realized. My brain shut down completely. There was nothing but fiery pain in my throat and the delicious blood – blood everywhere – promising to put that fire out. When it was over and there wasn’t a heart left beating on the whole ship, I wasn’t sure how many people I’d personal y kil ed. More than triple the number I’d ever had on a hunting trip before, easy. I felt hot and flushed. I’d drunk long past the point at which my thirst was total y slaked, just for the taste of the blood. Most of the blood on the ferry was clean and luscious – these passengers had not been dregs. Though I hadn’t held back, I was probably at the low end of the kil count. Raoul was so surrounded by mangled bodies that they actual y made a little hil . He sat on top of his pile of the dead and laughed loudly to himself.

He wasn’t the only one laughing. The dark boat was ful of sounds of delight. I heard Kristie say, “That was amazing – three cheers for Riley!” Some of her crowd put up a raucous chorus of hurrahs like a bunch of happy drunks.

Jen and Kevin swung onto the view deck, dripping wet. “Got

’em al, boss,” Jen cal ed to Riley. So some people must have tried to swim for it. I hadn’t noticed.

I looked around for Fred. It took me a while to find him. I final y realized that I couldn’t look directly at the back corner by the vending machines, and I headed that way. At first I felt like the rocking ferry was making me seasick, but then I got close enough that the feeling faded and I could see Fred standing by the window. He smiled at me quickly, and then looked over my head. I fol owed his gaze and saw that he was watching Riley. I got the feeling that he’d been doing this for some time.

“Okay, kids,” Riley said. “You’ve had a taste of the sweet life, but now we’ve got work to do!”

They al roared enthusiastical y.

“I’ve got three last things to tel you – and one of those things involves a little dessert – so let’s sink this scow and get home!”

With laughter mixed in with the snarls, the army went to work dismantling the boat. Fred and I bailed out the window and watched the demo from a short distance. It didn’t take long for the ferry to crumple in the middle with a loud groan of metal. The midsection went down first, with both the bow and the stern twisting up to point to the sky. They sank one at a time, the stern beating the bow by a few seconds. The school of barracuda headed toward us. Fred and I started swimming for shore. We ran home with the others – though keeping our distance. A couple of times Fred looked at me like he had something he wanted to say, but each time he seemed to change his mind. Back at the house, Riley let the celebratory mood wind down. Even after a few hours had passed, he stil had his hands ful trying to get everyone serious again. For once it wasn’t a fight he was trying to defuse, just high spirits. If Riley’s promises were false, as I thought, he was going to have an issue when the ambush was over. Now that al these vampires had real y feasted, they weren’t going to go back to any measure of restraint very easily. For tonight, though, Riley was a hero. Final y – a while after I would have guessed that the sun was up outside – everyone was quiet and paying attention. From their faces, it seemed they were ready to hear just about anything he had to say.

Riley stood halfway up the stairs, his face serious.

“Three things,” he began. “First, we want to be sure we get the right coven. If we accidental y run across another clan and slaughter them, we’l tip our hand. We want our enemies overconfident and unprepared. There are two things that mark this coven, and they’re pretty hard to miss. One, they look different – they have yel ow eyes.”

There was a murmur of confusion.

“Yel ow?” Raoul repeated in a disgusted tone.

“There’s a lot of the vampire world out there that you haven’t encountered yet. I told you these vampires were old. Their eyes are weaker than ours – yel owed with age. Another advantage to our side.” He nodded to himself as if to say, one down. “But other old vampires exist, so there is another way that we’l know them for sure… and this is where the dessert I mentioned comes into play.” Riley smiled slyly and waited a beat. “This is going to be hard to process,” he warned. “I don’t understand it, but I’ve seen it for myself. These old vampires have gone so soft that they actual y keep – as a member of their coven – a pet human.”

His revelation was met by blank silence. Total disbelief.

“I know – hard to swal ow. But it’s true. We’l know it’s definitely them because a human girl wil be with them.”

“Like… how?” Kristie asked. “You mean they carry meals around with them or something?”

“No, it’s always the same girl, just the one, and they don’t plan to kil her. I don’t know how they manage it, or why. Maybe they just like to be different. Maybe they want to show off their self-control. Maybe they think it makes them look stronger. It makes no sense to me. But I’ve seen her. More than that, I’ve smel ed her.”

Slow and dramatic, Riley reached into his jacket and pul ed out a smal ziplock bag with red fabric wadded up inside.

“I’ve done some recon in the past few weeks, checking the yel ow-eyes out as soon as they got near the area.” He paused to throw us a paternal look. “I watch out for my kids. Anyway, when I could tel that they were moving on us, I grabbed this” – he brandished the bag – “to help us track them. I want you al to get a lock on this scent.”

He handed the bag to Raoul, who opened the plastic zipper and inhaled deeply. He glanced up at Riley with a startled look.

“I know,” Riley said. “Amazing, right?”

Raoul handed the bag to Kevin, his eyes narrowing in thought.

One by one, each vampire sniffed the bag, and everyone reacted with wide eyes but little else. I was curious enough that I sidled away from Fred until I could feel a hint of the nausea and knew I was outside his circle. I crept forward until I was next to the Spider-Man kid, who seemed to be at the tail end of the line. He sniffed inside the bag when it was his turn and then seemed about to hand it back to the kid who had given it to him, but I held my hand out and hissed quietly. He did a double take – almost like he’d never see me before – and handed me the bag.

It looked like the red fabric was a shirt. I stuck my nose in the opening, keeping my eyes on the vampires near me, just in case, and inhaled.

Ah. I understood the expressions now and felt a similar one on my face. Because the human who had worn this shirt had seriously sweet blood. When Riley said dessert, he was dead right. On the other hand, I was less thirsty than I’d ever been. So while my eyes widened in appreciation, I didn’t feel enough pain in my throat to make me grimace. It would be awesome to taste this blood, but in that exact moment, it didn’t hurt me that I couldn’t.

I wondered how long it would take for me to get thirsty again. Usual y, a few hours after feeding, the pain would start to come back, and then it would just get worse and worse until – after a couple of days – it was impossible to ignore it even for a second. Would the excessive amount of blood I’d just drunk delay that? I guessed I’d see pretty soon.

I glanced around to make sure no one was waiting for the bag, because I thought Fred would probably be curious, too. Riley caught my eye, smiled the tiniest bit, and jerked his chin slightly toward the corner where Fred was. Which made me want to do the exact opposite of what I’d just been planning, but whatever. I didn’t want Riley to be suspicious of me. I walked back to Fred, ignoring the nausea until it faded and I was right next to him. I handed him the bag. He seemed pleased I’d thought to include him; he smiled and then sniffed the shirt. After a second he nodded thoughtful y to himself. He gave me the bag back with a significant look. The next time we were alone, I thought he would say aloud whatever it was he had seemed to want to share before.

I tossed the bag toward Spider-Man, who reacted like it had fal en out of the sky but stil caught it before it hit the ground. Everyone was buzzing about the scent. Riley clapped his hands together twice.

“Okay, so there’s the dessert I was talking about. The girl wil be with the yel ow-eyes. And whoever gets to her first gets dessert. Simple as that.”

Appreciative growls, competitive growls.

Simple, yes, but… wrong. Weren’t we supposed to be destroying the yel ow-eyed coven? Unity was supposed to be the key, not a first-come, first-served prize that only one vampire could win. The only guaranteed outcome from this plan was one dead human. I could think of half a dozen more productive ways to motivate this army. The one who kil s the most yel ow-eyes wins the girl. The one who shows the best team cooperation gets the girl. The one who sticks to the plan best. The one who fol ows orders best. MVP, etc. The focus should be on the danger, which was definitely not the human.

I looked around at the others and decided that none of them were fol owing the same train of thought. Raoul and Kristie were glaring at each other. I heard Sara and Jen arguing in whispers about the possibility of sharing the prize.

Wel, maybe Fred got it. He was frowning, too.

“And the last thing,” Riley said. For the first time there was some reluctance in his voice. “This wil probably be even harder to accept, so I’l show you. I won’t ask you to do anything I won’t do. Remember that – I’m with you guys every step of the way.”

The vampires got real stil again. I noticed that Raoul had the ziplock back and was gripping it possessively.

“There are so many things you have yet to learn about being a vampire,” Riley said. “Some of them make more sense than others. This is one of those things that won’t sound right at first, but I’ve experienced it myself, and I’l show you.” He deliberated for a long second. “Four times a year, the sun shines at a certain indirect angle. During that one day, four times a year, it is safe… for us to be outside in the daylight.”

Every tiny movement stopped. There was no breathing. Riley was talking to a bunch of statues.

“One of those special days is beginning now. The sun that is rising outside today won’t hurt any of us. And we are going to use this rare exception to surprise our enemies.”

My thoughts spun around and turned upside down. So Riley knew it was safe for us to go out in the sun. Or he didn’t, and our creator had told him this “four days a year” story. Or… this was true and Diego and I had lucked into one of those days. Except that Diego had been out in the shade before. And Riley was making this into some kind of solstice-y seasonal thing, while Diego and I had been safe in the daylight just four days ago. I could understand that Riley and our creator would want to control us with the fear of the sun. It made sense. But why tel the truth – in a very limited way – now?

I would bet it had to do with those scary dark-cloaks. She probably wanted to get a jump on her deadline. The cloaked ones had not promised to let her live when we kil ed al the yel ow-eyes. I guessed she would be off like a shot the second she’d accomplished her objective here. Kil the yel ow-eyes and then take an extended vacation in Australia or somewhere else on the other side of the world. And I’d bet she wasn’t going to send us engraved invitations. I would have to get to Diego quick so we could bail, too. In the opposite direction from Riley and our creator. And I ought to tip Fred off. I decided I would as soon as we had a moment alone.

There was so much manipulation going on in this one little speech, and I wasn’t sure I was catching it al . I wished Diego were here so we could analyze it together.

If Riley was just making up this four-days story on the spot, I guess I could understand why. It’s not like he could have just said, Hey, so I’ve lied to you for your whole lives, but now I’m telling the truth. He wanted us to fol ow him into battle today; he couldn’t undermine whatever trust he’d earned.

“It’s right for you to be terrified at the thought,” Riley told the statues. “The reason you are al stil alive is that you paid attention when I told you to be careful. You got home on time, you didn’t make mistakes. You let that fear make you smart and cautious. I don’t expect you to put that intel igent fear aside easily. I don’t expect you to run out that door on my word. But…”

He looked around the room once. “I do expect you to follow me out.”

His eyes slid away from the audience for just the teensiest fraction of a second, touching very briefly on something over my head.

“Watch me,” he told us. “Listen to me. Trust me. When you see that I’m okay, believe your eyes. The sun on this one day does have some interesting effects on our skin. You’l see. It won’t hurt you in any way. I wouldn’t do anything to put you guys in unnecessary danger. You know that.”

He started up the stairs.

“Riley, can’t we just wait – ,” Kristie began.

“Just pay attention,” Riley cut her off, stil moving up at a measured pace. “This gives us a big advantage. The yel oweyes know al about this day, but they don’t know that we know.”

As he was talking, he opened the door and walked out of the basement into the kitchen. There was no light in the wel -shaded kitchen, but everyone stil shied away from the open doorway. Everyone but me. His voice continued, moving toward the front door. “It takes most young vampires a while to embrace this exception – for good reason. Those who aren’t cautious about the daylight don’t last long.”

I felt Fred’s eyes on me. I glanced over at him. He was staring at me urgently, as if he wanted to take off but had nowhere to go.

“It’s okay,” I whispered almost silently. “The sun’s not going to hurt us.”

You trust him? he mouthed back at me.

No way.