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Still Stitching - Vintage Sewing Machines
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(Profile) Bob Riedel & The Girls
For those who frequent the Facebook groups dedicated to vintage sewing machines (VSMs), Bob Riedel is probably a familiar name. We know him as funny, accessible, and helpful.
He once sent me a few uncommon screws for a Wheeler and Wilson 9 and didn't think twice about shipping them before any reimbursement was exchanged. He allowed me to try the screws and ship back the ones that weren't useful. He also had me convinced recently in a chat session that the gears of a Singer Rocketeer had chewed off three of his fingers.
"I kind of feel bad now that you didn't know I was joking," Bob responded when I sort of freaked out. "Well, a tiny bit anyway."
Meet Bob (and The Girls)
Two beauties in red and black. Lizzy with a Singer 66.
Growing up primarily in the mountains of northern California and always mindful of his father's influence in industrial arts, Bob rebuilt his first automotive engine at age twelve: a Datsun 510.
"At age 14 my dad starting teaching me how to be a machinist," Bob explains. "I would hang out at his work, watching him make rocket motor parts in a huge machine shop."
After serving in the Navy on the aircraft carrier USS Nimits in Washington state, Bob liked the area so much he settled there as a civilian and worked in aerospace machine shops crafting parts for Boeing and Airbus for nine years. Eventually he landed in a smaller shop making electronic and medical parts. "It's a fun way to make a living," he tells us.
His road to vintage sewing machines was through his daughters, Becky and Lizzy. They loved their Barbie dolls.
They decided the Barbies needed new clothes so they started cutting out scraps of material we had laying around, some from old clothes, other scraps from whatever they could find. Well, to finish the Barbie clothes the girls were using my staplers to hold everything together. I started thinking there must be a better way; besides, the boxes of staples were getting expensive!
Bob remembered an old machine in his garage, once owned by his great aunt.
I took the machine to a local sewing machine shop and asked them to get it working. They said they could and would service it for $125. I also asked if they offered classes for beginner sewing. They gave me a brochure for the local CTA (Clothing and Textile Advisors) group for our area. So now we had a working machine and sewing lessons scheduled. Now we needed a second machine for my older daughter!
Becky wanted the same machine that Lizzy had, and Bob located a 401 on Craigslist. He was pleasantly surprised when he realized the seller had lived three houses away for the past fifteen years. The gentleman was knowledgeable and showed Bob how to care for the machine. "Little did I know," Bob says, "I was getting bitten by the bug!"
I am undoubtedly a collector, but I would clarify that as a "working collector." I collect machines that I think are cool but also machines I know the daughters will use... I enjoy the mechanical side of these wonderful machines! I'll pull the top cover and just watch all the parts moving and see how this part interacts with that part. I look at these machines from a machinist viewpoint and am constantly amazed at the parts and pieces manufactured back then.
Becky applies Blue Creeper as she performs maintenance on her Rocketeer.
Bob and his girls remain loyal to the Singer slant needle models. The 401s led to Rocketeers but many machines fill their arsenal, including treadles like a Wheeler and Wilson #8 and a D9.
I'm not sure how many machines we have other then at least one of each slant up to the 431. We don't have designated machines for a single purpose, it's more like which machine do I feel like using today or which one has the thread color I need. The girls also enjoy sewing out in the back yard in the summer on their 301's.
Becky sews outdoors.
He tells us that VSMs are abundant and often priced nicely in his part of the country. Nonetheless it took a while to locate his most desired model and he had to travel to obtain it.
Last year a fellow member [of a VSM Facebook group] sent me a message saying my holy grail was for sale near her. We loaded up the car and drove 300 miles one way to finally get my coveted 431G! I was absolutely thrilled. It was expensive but looking on eBay I never figured I could ever afford one. A week after our road trip I had to head over to Seattle for work. On the way home I saw an estate sale so I figured I'd stop quick. There in the back room was another very nice 431G for $10! I have since rehomed the first 431 to my friend who gave me the initial heads up.
The coveted beast - Bob's Singer 431G.
On another occasion Bob and the girls trekked 60 miles for a pink Morse. His daughters were excited for the "new" machine, and the trip also yielded a Wheeler and Wilson D-9 head that Bob needed for its bobbin. He picked up the D-9 for "a couple of bucks."
Score and score! We were all happy on the way home and then my younger daughter spied a thrift store so we hung a u-turn and went in. I saw a Singer case behind the counter which I couldn't quite identify. I asked the lady if we could see it and our jaws dropped as she pulled the top off a pristine 201K23 two-tone brown hand crank! It still had the factory Singer protective paper in the bottom. I asked what they wanted so the lady went to talk to the manager. I told the girls if it was anywhere under $100 we were grabbing it. She came back and said for the girls it was $99! They were squealing and the pink Morse was totally forgotten. In fact it's still out in the garage waiting to be rehomed.
Bob believes in helping others to enjoy classic all-metal machines. He doesn't presently operate a business repairing VSMs, but might consider doing so in retirement. In the meantime, he finds ways to support others who need a bit of assistance.
I spotted a 500 Rocketeer on Craigslist so I went to check it out. The lady had five sewing machines on the table when I walked in. She said they were all for sale. I said, "I'm interested in the 500 but why are you selling all these?" She explained that none worked and she couldn't afford to get them fixed or serviced. I asked her if I repaired and serviced the 500 would she keep it and use it. The look of gratitude on that lady's face when I brought it back two weeks later is something I'll never forget. That is why I enjoy this!
Doll clothing by Lizzy.
While his daughters are the primary sewists, having attended classes at the local CTA (Clothing and Textile Advisers), Bob can manage a stitch to test his machines and even completed a small project - a Christmas stocking. "It was fun and I quilted it on the Wheeler and Wilson #8 and finished the end with the 431."
I asked Bob how he would explain the value and appeal of the vintage machines to someone who knew very little.
Most of the time I don't need to say a word. They just stand there watching and listening and the machines sell themselves. There have been a few times the young ladies in sewing camp have asked to use my daughters' machines to get through a few heavy layers, because their machines sound like they are going to explode. I do explain how well they are built and why they will last a few more lifetimes if taken care of. I also stress how these machines were made to be maintained by the owner, and you don't have to have costly services every year.
And finally, what machines remain on Bob's wish list?
I am still hoping someday to find a Singer 320 and a German Singer slant treadle. Neither are common here and most likely unaffordable anyway. It's still the thrill of the hunt and always wondering what's in that cabinet or under that cover that keeps me intrigued.
Our thanks to Bob Riedel for the knowledge and humor he brings to our community. Our thanks to Lizzy and Becky as well. In an age of throw-away appliances and waning domestic skills, we congratulate Bob's effort to ensure his daughters develop self-sufficiency as they relish their childhood.
Lizzy sews on a Wheeler and Wilson 8, a machine more than 100 years old.
Becky stands with her Social Studies project on the Singer Company. She earned a blue ribbon.
From the Riedel arsenal, a beautiful Singer 412G.
Catagories: Collector Interviews, Vintage Sewing Machines
What We Do at Still Stitching:
We produced the only feature-length documentary on vintage sewing machines. Still Stitching has delighted thousands of viewers and urged the expansion of many collections. Many viewers tell us they watch it repeatedly. Ladies tell us that the film helped draw their husbands into their passion for vintage machines.
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We are fortunate to assist many clients with procurement, high-end restoration, and custom painting of vintage sewing machines. While Singer 221 Featherweights are the most frequently painted model, we paint many other models such as the Singer 15, 66, 99, 201, and 301. We also refinish cabinets, treadle irons, and vintage sewing machine cases. Interested in our services? Contact us!
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CUB case: All ratepayers matter
By Steve Baas
For many years, the Madison-based Citizen's Utility Board has been one of a number of voices that weigh in on public utility rate cases. CUB's traditional operational model, much like a chamber of commerce's, was to garner voluntary financial support from utility ratepayers by persuading them of the merits of their positions and of the value of their advocacy.
But in 2009 CUB persuaded lawmakers to pass legislation carving out special funding for its organization. That funding was generated by mandatory assessments on utility ratepayers and could be used for employee salaries and other office operational costs. Recently, the Metropolitan Milwaukee Association of Commerce petitioned the Joint Finance Committee to eliminate this dedicated funding stream that comes at the expense of utility ratepayers.
Wisconsin has a long tradition of an independent Public Service Commission charged with reviewing and approving all utility rates in Wisconsin. CUB has an important role to play in representing the ideology and interests of its members before the PSC. However, CUB is only one in a cacophony of diverse voices, individual and organizational, that weigh in on utility rate issues before the PSC. Sometimes, the positions taken by these various individuals and groups differ. Yet only CUB has enjoyed the benefit of special funding from ratepayers. We believe that is fundamentally unfair. By singling out one organization for a special ratepayer subsidy, the existing state law essentially puts its finger on the scale of democracy and places all other competing ratepayer voices at a disadvantage with CUB.
In addition, MMAC also supported a change requiring organizations who seek intervenor compensation funding for their advocacy before the PSC to provide a 50% match for the ratepayer dollars they are requesting to support their claims. This "skin in the game" will ensure intervenor compensation funds are used responsibly by providing a disincentive for frivolous or redundant cases before the PSC.
Case in point: CUB recently received ratepayer-funded compensation to ask the PSC to double the steam rates for property owners, renters and businesses in downtown Milwaukee. CUB argued that the resulting electric rate decrease would have saved outstate utility customers roughly one-tenth of one percent. This case was brought not once, but twice within the space of one year, costing other ratepayer voices in opposition to CUB's position tens of thousands of dollars in legal costs.
CUB has every right to bring its members' voice to debates over utility rate cases, but that voice should not be singled out for preferential treatment via a special financial arrangement from the state. The PSC will continue to review utility rate requests, invite input from all ratepayer voices, and make adjustments as they judge necessary, regardless of whether CUB retains its preferred political status and subsidy or whether it returns to its historic role as an actual independent, customer-funded advocacy entity.
Our advocacy on behalf of the reforms recently adopted by the Joint Committee on Finance is fueled by our belief that all ratepayer voices matter, and that the public interest is served best when all of them are given the opportunity to speak up for their interests without the state playing favorites by subsidizing only one of them.
Steve Baas is vice president of government affairs for the Metropolitan Milwaukee Association of Commerce.
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Sex and Language as Pretend-Play
Lie and alternative, inherent in language pose problems to any society whose structure is founded on language, which is to say all human societies. I have therefore argued that if there are to be words at all it is necessary to establish The Word, and that The Word is established by the invariance of liturgy
Rappaport 1979: 210—11
Language can be studied independently, or as an aspect of human sociality. Theoretical linguistics could not exist as a discipline were it not for the relative autonomy of language as a system. Ultimately, however, this system functions within a wider domain of signals which include cosmetics, dress, art, ritual and much else whose study takes us beyond linguistics.
A Darwinian theory of the origins of language must therefore address two issues. Firstly, it must explain the relative autonomy of language. Secondly, it must elucidate the evolutionary relationship between speech and a wider biological, social and symbolic domain of signals and displays.
Primates negotiate socially through displays of dominance, submission, appeasement, threat, sexual arousal and so forth. Each vocal signal forms part of a more complex visual-auditory display which includes posture and facial expression. A chimpanzee may express fear, for example, by a 'pant-scream' accompanied by a 'grin'. Presentation of the rump accompanied by a 'pant-grunt' signals 'respect'. Very different is the intimidatory 'roaring pant-hoot' of an aroused chimpanzee male. Consisting of a series of low-pitched calls, this is always accompanied by a charging display (Goodall 1986: 114—45, 360).
The point about calls of this kind is that they have not been decoupled as low-cost conventional tokens from the wider system of energetically demanding display. In the human case, such decoupling has evidently occurred, giving rise to a tokenistic, digitally organized system — speech — operating on a level quite independent of bodily display (Burling 1993).
At some point in the evolutionary past, the ancestors of modern humans must have had a repertoire of primate-style gestures and displays. Signals of this kind live on as the human species' own gesture-call system — a 'universal language' of smiles, frowns and other 'hard to fake' emotional expressions including laughter, crying and so forth (Burling 1993; Ekman 1982). However, while important on the level of personal relationships, in the human case this system no longer carries the main burden of expressing and constituting sociopolitical structure at the global level. Rather, in the case of human hunter-gatherers and other pre-state societies, this function of exciting, mobilizing and giving expression to collective structural relationships has been taken over by ritual. In all traditional cultures, humans invest enormous amounts of energy in the ritual domain. Unlike speech, ritual signals are not confined to a single channel; neither are they necessarily effective in communicating complex trains of thought. Like animal gesture/calls, human ritual displays are characteristically loud, multimedia, emotionally infectious and heavily redundant (Rappaport 1979: 173—246).
Despite evidence of evolutionary continuity human ritual signals differ from their animal counterparts in two ways. Firstly, structure-generating ritual performances are staged not by individuals acting independently but by whole coalitions, whose members dance, drum, sing or otherwise rhythmically coordinate in asserting group identity and a boundary against outsiders (see, for example, Cohen 1985; Harrison 1993). In the human case, moreover, the cognitive outcome is an internal domain of communal pretend-play or 'counter-reality'. Human ritual performance, when successful, generates a whole new cognitive domain — a virtual world discernible on another representational level from the currently perceptible or 'real' one (Durkheim 1912; Gellner 1992: 36—7; Turner 1967).
In speech, pressure for communicative speed and efficiency selects heavily against costly display in favour of tokenistic signalling. In ritual performance, reverse pressures apply, driving signallers to prolong, to repeat and to incur heavy costs. Ritual signals cannot be replaced by tokens without loss of effect. In trance-inducing rhythmic drumming, for example, nothing short of the direct physical and emotional impact of hands repeatedly hitting drumskins will do. Percussionists are not supposed to drum tokenistically. Or take the example of wailing or other public expressions of grief at a funeral. It is the wrenching, costly body-signals which matter, especially when these appear irrepressible. Where mourners remain dispassionate, resorting simply to tokens, there may be little point in staging the ritual at all. In ritual, to lose the display, replacing it by a conventional token, is simply to lose the signal.
Intrinsic credibility or 'indexicality' (Pierce 1940) is, then, the hallmark of ritual signals. Paradoxically, however, such signals are deployed within ritual precisely to displace the individual's reality-based cognition, substituting a collectively defined 'other-world' (cf. Chase, this volume). A funeral occurs when a loved one has died. It is precisely that disturbing social absence which provokes counter-measures, the deceased's continued 'presence' being constructed by emotionally convincing display. If the illusory realm generated by ritual fails to eclipse 'this world', then some thing is wrong. This is why we feel irritated by someone munching food or otherwise distracting attention during a visit to the theatre. Like a stage-show or television soap-opera, ritual must successfully interfere with the processes of ordinary perception/cognition (Bloch 1985), enabling par ticipants to cut adrift from their own personal reality into an alternative, communal one. At the theatre, reality fades as the auditorium lights are dimmed. A hush descends and the curtain slowly rises, revealing a well-lit stage. We are wafted into another world.
Ancient Greek theatre evolved from ritual. Pre-state societies may not have theatre in the modern sense, but everywhere, performances are staged in giving tangible form to myth (Fontenrose 1959; Warner 1959). Cross culturally, ritual time tends to begin around dusk, when shadows lurk and the hold of reality fails. Trance-inducing dance, fasting and/or hallucinogens may enhance the effect. The whole point of all this is to make people see 'beyond' perceptible reality into the other-worldly domain — that of morally authoritative intangibles (cf. Turner 1967: 93—111). The gods and spirits, normally invisible, must be experienced at least periodically as more real than reality itself.
THE RELATIONSHIP BETWEEN SPEECH AND RITUAL
Primate gesture/calls, then, are holistic, both audible and visible signals being embedded in a unitary system of display. By contrast, in the human case, 'ritual' constitutes a gestural system differentiated from vocal speech, the two having evolved along divergent trajectories (see Table 12.1).
To these contrasts we can add another, arrived at by inference on the basis of Darwinian signal-evolution theory (Dawkins and Krebs 1984; Zahavi 1987, 1993; see discussion in Knight et al. 1995). According to this body of theory, where we find high-cost, repetitive, multimedia displays, we may infer a function in terms of social manipulation, conflict and exploitation. Resistance on the part of receivers sets up selection pressures acting on signal design. Signallers who encounter 'sales resistance', like modern commercial advertisers, are driven to respond by prolonging and repeating signals, increasing amplitude and resorting to costly multi media displays. Peacocks provide examples of this, as do caribou bulls bellowing at one another during the rutting season. Zahavi (1987) has shown how the discernible costs of such displays enhance their credibility by tapping and hence testing the very reservoirs of quality that signallers are attempting to advertise. High-cost signalling of this kind may be regarded as representing a victory on the part of sceptical receivers spurring signallers to ever greater competitive effort.
Table 12.1 Signals: speech versus ritual
Cheap signals Costly signals
Interpersonal Group-on-group
Two-way communication One-way signals
Low amplitude High amplitude
Dispassionate Emotive
Vocal-auditory Multi-media
Discrete-combinatorial Holistic
Productivity/creativity Repetition/redundancy
Stress on novelty Stress on conservatism
Conventionally coded Iconic and indexical
Focus on underlying intentions Focus on body-boundaries and surfaces
By contrast, where we find low-cost, quiet and efficient signals, a co-operative audience can be inferred. If signallers can afford to cut their emission costs, it can only be because listeners are investing corresponding effort in receiving, decoding and acting on signals. This in turn means that signallers and receivers must have shared interests. For such 'conspiratorial whispering' (Dawkins and Krebs 1984) to evolve, signallers must be imparting useful information to receivers. Logically, the ultimate cost-cutting strategy would be to resort to purely tokenistic, wholly conventional signals which can be processed categorically at speed — relieving listeners of the need to evaluate gradations in physical performance. According to Zahavi (1993), however, animal 'conspiracies' are never sufficiently cooperative. Internal conflict and scepticism precludes ultimate reliance on tokenistic 'paper money'. Nowhere in the living world do we find purely conventional signalling — with the one puzzling exception of human speech.
This discussion allows us to establish one more contrast — this time functional — between speech and ritual. On the basis of Darwinian signal evolution theory, it can be inferred that speech emerged in a cooperative context while ritual did not. For speech to have evolved, 'conspiratorial whispering' in the human case must have been anomalously trusting. By contrast, ritual — with its costly, inefficient features of redundancy and display — can only have emerged out of conflict, manipulation and exploitation.
FORM AND FUNCTION OF RITUAL SIGNALS
Speech is utterly different from ritual. Yet there remains a connection. Opposition is itself a relationship, and it is clear that speech could have no force or function were it not for its paradoxical connection with ritual.
The inscription on a banknote — 'I promise to pay the bearer on demand' — inspires trust only thanks to a system of state printing controls, counterfeit detection and law enforcement including court proceedings and punishment for fraudulent abuse. We are able to use banknotes, then, thanks only to a system of communal action quite external to the paper used to print them. Hunter-gatherer societies are stateless. They lack courts, prisons, money or specialist law-enforcement agencies (Engels 1972 [1884]) However, they do perform rituals. My argument is that costly ritual is the pre-state system of communal action which backs up the otherwise valueless tokens central to speech.
Words resemble banknotes in that they are intrinsically worthless, requiring an external system of controls if they are to be usable at all (Knight 1998). Like commercial transactions, 'speech acts', as Austin (1978) has shown, are social transactions dependent on communal validation for their force. The implicit or explicit contracts by which speakers bind themselves are morally authoritative intangibles. But how is it that such intangibles are representable? 'What, for example, is a promise? Can such a thing be seen, heard, tasted, kicked or by any means perceived? Could a group of chimpanzees trade in entities of this kind?
To deal in social contracts is to agree to enter a virtual world, not unlike that of a board game such as Monopoly. Just as Monopoly money cannot be used without a display of commitment on the part of players, so 'promising' presupposes a certain background of commitments and formal expectations. Suppose I preface my propositional utterance with an oath — 'I swear to tell the truth, the whole truth and nothing but the truth'. For this to count, I must signal by my clothes, my evident situation or in other ways that I am someone of appropriate moral status — the right person to utter such words in this place and at this time. Only then will my oath be accepted as valid ( Austin 1978). In short, a promise exists only in the context of commitment to a kind of game. Like an oath, its successful enactment is best thought of as a hard-to-fake, communally verifiable display of commitment or obligation. Only a speaker who can deliver on the hard-to-fake components of his signal can deploy the cheap tokens — 'words' — through which collusion in the verbal transaction is secured (cf. Austin 1978; Bourdieu 1992).
A human cultural system may be immeasurably more complex than any game of pretend-play. But just as a game is constructed out of pretend-play tokens and rules, so human symbolic culture in general is composed en-tirely of entities constructed via a kind of play.
It is such play which allows the Jalé of Papua New Guinea to restrict themselves to a lexicon featuring just two basic colour terms — roughly 'dark' and 'light'. In other cultures, playing by other rules which demand a further term, 'red' is predictably the next one to emerge (Berlin and Kay 1969). It need hardly be stressed that such minimal discriminations operate on a level quite independent of personal colour perception: all humans, in all cultures, discriminate perceptually between an immense variety of different colours. To take another well-known example, among the Nuer, named categories of time are those defined by shared ritual experiences specific to the culture, such as 'the time of milking the cattle', 'when the calves come home' and so forth (Evans-Pritchard 1940: 100-8). Here again, it is the ritual structure which defines the categories — this time temporal — which are available to be named.
Within a ceremonial house among the Kabyle in North Africa, the dry, light area of floor-space counts as 'the place of honour' while the darker, moister area is 'the place of the tomb' (Bourdieu 1990). No one in the dwelling who remained unaware of this distinction could speak or act within the house in an appropriate way. An Australian Aboriginal landscape is in a comparable way 'totemic' — structured by morally authoritative intangibles. Here, the red stains in a rock mark a mythical being's bloody death; there, a misshapen boulder is all that remains of a Dreamtime ancestor; in this pool dwells the fearsome 'Rainbow Snake' (Barnard, this volume; Mountford 1978; Strehlow 1947).
Such examples show how every linguistic term for a discriminable 'thing' in symbolic culture is tokenistic of some game-defined entity, in principle no different from the pretend-play components of a Monopoly game. Words do not map to external, perceptible realities — only to things established as 'real' through the playing out of the local game. This is why I would argue, contrary to Chase (this volume), that symbolic reference and symbolic culture are logically inseparable and so must have evolved together.
On the one hand, then, there is the perceptual level of representation. Life is made up of realities such as a chimpanzee might spontaneously perceive — realities such as the hardness or taste of a Monopoly board, or the clothing or body-odour of one of the players. But on the other hand, participants in game-like domains must negotiate their way through a virtual world — a world of contractual intangibles which 'exist' only because it is agreed to act collectively 'as if' they did. Ritual is this collective acting out. It is not an optional add-on with respect to the rest of symbolic culture. It is the actual playing of the game — life conducted 'as if' the gods or other morally authoritative intangibles were real (cf. Chase, this volume).
In entering into the spirit of a game, each player must override physical reality, which now becomes external to the game's own illusory domain. Suppose, for example, one player of Monopoly is larger or more muscular than another. This is irrelevant: it does not permit the stronger partner to take advantage. To play properly, the players must set aside the dispositions applicable in ordinary life in favour of the quite different rules internal to the game. Each player must undergo a kind of conversion experience, analogous to an initiation rite, after which nothing remains what it seemed. Portions of worthless cardboard now count as 'streets', small bits of wood are 'houses', bits of paper are 'banknotes'. Such eclipsing of reality transports participants into a shared domain of acted-out fantasy which constitutes the game.
In pre-state societies, 'rites of passage' (Van Gennep 1960) are designed to bring about in each individual precisely that 'conversion experience' necessary for the local game to appear playable. Only once the gods, spirits and comparable intangibles seem experientially real are individuals in a position to function within the symbolic domain. There are good reasons why initiation rites tend to be painful, manipulative, coercive and generally 'unfair'. The reason is the same as that which makes all ritual unfair. Ritual, like warfare, cannot afford to assume that there are any rules.
It may seem paradoxical to reflect that while game-like behaviour must by definition be 'fair', ritual signals cannot be. The explanation is that if behaviour is to be judged as fair, a set of rules for making such evaluations must already exist. But what if no one wants to play by the rules? Imagine a festive family gathering spurning Monopoly in favour of socializing, eating or watching television. To get them to play, it will clearly be useless to offer Monopoly banknotes as bribes. All other tokenistic appeals will equally fail. The only solution is to step outside such pretend-play, intervening in reality itself Loudly halt the conversation, take the food off the table, switch off the television. The convenor must 'cheat' in order to get people to play, switching off their involvement in perceptible reality, amplifying the attractions of pretend-play, overstepping all rules in securing compliance with rule.
This is the task of ritual. Like civil war, its function is to assert physical mastery by a particular coalition dictating the terrain on which future games are to be played. It is therefore no surprise to find that ritual signals differ from words in presupposing no prior adherence or commitment. Ritual, like violence, impacts on its human victims directly, seeking out vulnerable spots in the targeted biological and psychological material. Coercive intimidation, hallucination, dance, rhythm, seduction and emotional manipulation all have their place. In much of Aboriginal Australia, boys were initiated into rule-governed adulthood by having their genitals attacked in practices ranging from circumcision to the excruciating ordeal of subincision (Montagu 1974). If part of the definition of 'fairness' is two-way negotiation on the basis of agreed rule, then this was clearly unfair. But all ritual signals have to work like this. To secure commitment to the world of 'rules' and other such communal make-believe, the habits and dispositions of ordinary life must first be coercively defeated (Bloch 1985). We can put this another way by saying that no one would be 'taken in' by ritual signals with their improbable 'other-worldly' messages if such signals did not hit below the belt, using what by rational or logical standards would seem unfair methods of persuasion.
EVOLUTION OF COLLECTIVE DECEPTION: THE 'WARFARE' MODEL
Young primates may engage in play — such as play-fighting — which pre pares them for adult life (Bruner et al. 1976). But they do not engage in communal pretend-play — play in which all agree to act out an imaginary scenario. Even if they were capable of this, it seems doubtful whether they would have a motive. Why invest energy in colluding with someone else's illusory world when the real one is so much more engaging?
Of course, primates do not engage only with reality. Primate 'tactical deception' has been closely studied, in part because it arguably prefigures human 'symbolic' usage. In the primate case, however, reality-defying signalling is not cooperative. It is always 'Machiavellian', individualistic and competitive. Suppose a baboon falsely signals by its posture that it has seen a threatening leopard, seeking by this deceptive signal to gain a selfish advantage (cf. Byrne and Whiten 1985). Can we speak of the fictional leopard as 'symbolic'? Clearly not. The signaller's selfishness means that conspecifics will have no reason to collude with the fiction. The imaginary 'leopard' will therefore not be taken up by others and sustained. Once the fiction is exposed, all interest in it will disappear. On this basis, 'memic' evolution of fictions (Dawkins 1976) will simply never get off the ground.
Collectively sustained deception, by contrast, is the essence of the game-playing known as 'symbolic culture'. How close do chimpanzees get to this in the wild? When a group of common chimps raids into a neighbouring territory, the leaders may insist on silence from the whole band, enforcing this through reprimands (Goodall 1986: 490-1). Although the group is now physically present in the invaded neighbourhood, we might say that its members are 'pretending' not to be. However, this still falls short of symbolism. Silence provides no fictional signal which can be collectively elaborated or sustained. To generate symbolism, communal pretend-play would have to go a step further — from cooperative non-signalling to active reality-defying display.
Coalitions strong enough to constrain their members' behaviour do not form in a vacuum. They need an external threat capable of generating internal cohesion on the necessary scale. It has been suggested that evolving Homo recurrently engaged in group-on-group contests equalling or exceeding ingroup/outgroup conflict between neighbouring bands of common chimpanzees; ingroup 'moral' codes may have emerged in such contexts (Alexander 1989). This theory would lead us to suppose that something akin to 'war' drove the evolutionary emergence of human morality and symbolic culture.
It must be conceded that 'primitive warfare' provides a plausible context for the emergence of collective deception. Success in warfare depends not merely on direct physical violence but also on psychological factors such as surprise, intimidatory display, rumour and the advance dissemination of fear. Turning to the evolution of Homo, it is not difficult to picture early prefigurations of such group-on-group psychological tactics, and to understand how they may have led some way down the road towards symbolism.
Aggressive displays by coalitions of pre-modern humans would have had internal as well as external functions, coming under correspondingly contrasting selection pressures. Within an aggressive coalition, while pre paring to fight, individuals can afford to communicate their intentions internally by means of cryptic 'nods' and 'winks'. In other words, short-hand, abbreviated versions of the behavioural routines involved in coalitionary defence or war preparations may suffice in such contexts. However, given the risks of reliance on cheap signals (Zahavi 1987, 1993), even such internal tokenism will remain ultimately dependent on the shared obligation to resort at least periodically to genuine fighting. Only each individual's sustained display of genuine commitment to fight the enemy — clearly, a costly signal — will generate the internal trust necessary for low-cost ingroup tokens to work.
Here, then, we have a possible solution to our basic question: How did 'speech' become decoupled so decisively from 'ritual'? The 'primitive war-fare' model (Alexander 1989) suggests an answer: this decoupling was a consequence of group-on-group conflict, which — to the extent that firm ingroup/outgroup boundaries became established — drove ingroup signalling down one evolutionary trajectory and external signalling along a radically divergent one, the two systems nonetheless remaining mutually interdependent.
Aggressive displays are iconic and indexical (Peirce 1940): just as smoke means fire, so a body of men performing a war dance means war. When I see and hear the signs of an approaching army, I am persuaded to flee neither by symbolic metaphor, nor by assent to any code, but directly in proportion as the drums, pennants and weaponry seem to demonstrate the threat posed by that force. The signals, then, work only by claiming a verifiable fit with the currently perceptible world. Suppose I deduce that the displays are mere bluff, exaggerated out of all proportion to the violence which can really be mounted. Then the signals have failed in their purpose.
This is a weakness in the theory that symbolism arose out of group on-group conflict or 'warfare'. It would seem that the model cannot get beyond indexicality — signals which remain ultimately reality-bound. 'What, then, of the 'counter-reality' which constitutes human cultural symbolism? In this, signals can be seen, perceptually, to bear no relationship to reality Yet far from nullifying the message, recognition of such patent pretend-play prompts a search for meaning 'on another level'. In observing the pretend-play, we ask: What is the signaller intending us to understand (cf. Grice 1969)?
In this context, the kinds of conflict intrinsic to 'warfare' may be simply too unremitting to generate symbolic culture. No army can afford to see through the enemy's bluff, discern the signalling intention — and then collude with that intention. Yet cooperation of this kind is precisely what symbolic communication entails. Every signal, viewed in terms of its own intrinsic properties, is wholly unconvincing. This being so, we seek to discern what the signaller is attempting to convey (Grice 1969). The difference between ritual display and the use of symbolic tokens is that the former does not assume prior collusion — ritual faces the task of securing cooperation from the target, whether by fair means or foul. Cooperation in symbolic performance, whether ritual or verbal, by contrast does assume prior collusion. Even should the audience 'see' on a perceptual level that everything is pure pretence, they must still suspend disbelief. It is difficult to see how 'warfare' could bring this about.
In addition to this difficulty, the 'warfare' model fails to capture the essence of hunter-gatherer ritual as a means of demarcating ingroup/outgroup boundaries. In warfare, each army or aggressive coalition wins on some occasions, loses on others. By contrast, human hunter-gatherers invest enormous amounts of energy in elaborate ritual performances which are not expected to fail. Investment in performances such as initiation rites in normal times far outweighs investment in violence aimed at territorial neighbours. In fact, Australian Aboriginal ritual structures appear designed precisely to transcend simple ingroup/outgroup territorial conflict, setting up 'chains of connection' — structures of ritually defined interdependence — stretching across the landscape. In north-east Arnhem Land , Australia , a major initiation ceremony such as the Djungguan gathered together clans normally dispersed over a wide area, often speaking mutually incomprehensible dialects (Warner 1957). A simple 'territorial warfare' model would not predict any of this.
THE EVOLUTION OF INITIATION RITES
Ritual is not quite the same thing as war, although it may be valid to conceptualize it as 'war by other means'. A crucial difference is that warfare relies overwhelmingly on physical violence. Ritual by no means excludes violence, but performers reduce the costs of actual fighting by resorting in the first instance to display. Ritual display, moreover, is not necessarily or exclusively aggressive or intimidatory — it may equally be seductive (cf. Miller, Power this volume). Hence while military strategies can be discussed without reference to sexual strategies, this is not possible in the case of ritual action. When dancers prepare for a collective ritual display, all the signalling potentialities of the human body are in principle there to be drawn upon. Hunter-gatherer ritual performances in fact establish ingroup/outgroup boundaries recurrently coinciding with those between exogamous kin-groups. The aim is less to kill than to impress the enemy and in consequence to secure the best possible deal in marital exchanges with the outgroup — using not only threats but gifts and all available techniques of manipulation, exploitation and seduction (Knight 1991).
For Darwinians, a deeply rooted and pervasive form of intraspecific 'warfare' is the inevitability of conflict between the sexes (Dawkins 1976; Trivers 1972; Hill and Kaplan 1988). A model of human ritual as originating in 'warfare' pitting all females against all males would clearly be unrealistic. However, females are related to males not only as mates/ spouses. They are also mothers/sisters/kin. If the concept of sexual conflict is integrated with that of coalitionary kin-bonding, we may construct a model of sexual 'warfare' which has promising potential to account for the emergence of symbolic culture in forms consistent with data from the hunter-gatherer ethnographic record.
Suppose males in alliance with sisters and other kin conduct 'warfare' against outgroup males, seeking to exploit their muscle-power by offering marital access only in return for provisioning. This is not an unreasonable idea: hunter-gatherer 'brideservice' embodies precisely this principle. A young man seeking a bride first has to prove himself as a hunter. When he has made a kill, he may stand a chance of sexual acceptance. He takes the meat to the kin of his chosen bride. They may inspect the meat and, if satisfied, allow the young man to stay a night. If he wants future sex, he will have to bring more meat. Should he prove unlucky, lazy or incompetent, he may be told to stay away. To avoid unwanted liaisons, many hunter-gatherers remain distrustful of sons-in-law for years, preventing them from asserting permanent marital rights in their brides. Even after a child has been born, the young man will usually be expected to make substantial regular contributions of meat to both the bride and her kin (Collier and Rosaldo 1981; see discussion in Knight 1991: 122-53).
Success in this strategy presupposes women's ability to mobilize male kin where necessary against uncooperative mates or spouses. 'Where this condition is met, the relationship between wife's kin and in-marrying bridegroom may be emphatically hierarchical and one-sided. Among many hunter-gatherers, a male will not even be considered as a potential son-in-law before he has undergone initiation, the function of which is to teach him what ritual obligation means. There must be no answering back. Victory to the 'wife-givers' is predetermined long in advance (Knight 1991: 122-53). If this is 'war', then, it is peculiar in that the same side invariably wins. This may seem less puzzling, however, when we remember that for the 'defeated' side, there is much consolation. The 'exploited' outgroup males are in fact being allowed access to the group's fertile females. The reproductive fitness of these males will be enhanced if they obtain hunted meat not in order to eat it themselves but as a form of currency which can be traded for sexual access, with the benefits accruing to their offspring (cf. Hill and Kaplan 1988). On Darwinian grounds, we would not expect these males to resist such 'exploitative' arrangements beyond a certain point.
In all this, loud ritual signals are securing coalitionary dominance in order to maintain a system of economic 'exploitation'. The immediate beneficiaries are coalitionary alliances of mothers and their offspring, who would otherwise be unable to secure comparable meat-supplies (cf. Key and Aiello, this volume). Note, however, that the strategy is one in which males as mates are being exploited not by females acting alone but by mixed-sex kin-based coalitions. Ingroup males, no less than females, are engaging in the necessary economic 'exploitation' of outgroup males who in turn — as brothers in relation to their own kinswomen — help sisters/mothers 'exploit' their in-marrying spouses and sons-in-law.
In evolutionary perspective, the emergence of such coalitionary strategies may be seen as female-driven (Power and Aiello 1997). Evolving human females, heavily burdened with increasingly encephalized, slow-developing offspring, would have been under pressure to secure investment from wherever this could be obtained. Support in rearing offspring could potentially be enlisted from (a) local kin-related females, (b) kin related males and (c) male sexual partners. I have argued (Knight 1991; Knight et al. 1995) that the optimal strategy was to draw on support from all three, securing coalitionary backing from (a) and (b) in the task of economically exploiting (c). Females enhanced their fitness, if this model is accepted, by combining sexual allure with coalitionary organizing skills aimed at maximizing 'brideservice' exploitation of spouses.
To make this model testable, we may explore its internal logic, drawing out theoretical predictions which can then be checked against the findings of hunter-gatherer ethnographers, archaeologists, rock-art specialists and others with relevant test-data.
A major problem would have been posed by menstrual bleeding. When she menstruates, a female signals her imminent fertility. For reasons quite independent of 'culture', this amounts to a 'danger' signal to all other females in the vicinity (Power, this volume). The problem for pregnant and lactating mothers is that they cannot display such blood. The all-too-evident distinction set up between the menstruant and other local females tells philanderer males whom to bond with and whom to temporarily abandon. Left to themselves, males under such circumstances may compete for access only to cycling (hence fertilizable) females. Success may then go to those dominant males best at abandoning any pregnant or breast-feeding partner in favour of a newly menstruating female — best at driving off the competition, bonding with the menstruant and mate-guarding her until impregnation has been achieved. Subdominant males may then find themselves threatened with loss of their sexual partners at the very moment when these are imminently fertile. As males compete for access to visibly menstruating females, non-cycling females will lose out, abandoned by their distracted mates.
In real life, however, every male strategy for asserting monopoly control over female reproductive value is likely to be met by a female counter-strategy (Gowaty 1997). Again quite independently of 'culture', a mother should simply not allow her menstruating daughter to be coopted and privatized under male sexual dominance. Defending against this possibility, she should bond tightly with the especially valuable female at precisely such a time. Sisters, brothers and other close relatives should equally feel threatened, bond with her and resist on her behalf.
As Power (this volume) has pointed out, the obvious additional counter-strategy for females threatened temporarily by their inability to menstruate is to cheat. Thanks to the intrinsic nature of the signal, which offers shareable blood, cheating is a possibility What can prevent pregnant and breast-feeding mothers from painting up anyway with surrogate 'menstrual' blood? In this context, any red pigment — a daughter's menstrual blood, blood from an animal, red berry juice, red ochre — may serve the purpose. Dominant males may in theory still draw a dividing line between genuinely and artificially menstruating females. But this can be countered if local females physically bond with any menstruant, preventing active discrimination between them.
The outcome will be a situation in which, whenever a woman menstruates, the signal sparks a contest. On the one hand, this is a contest for dominance between sexually motivated males. But on the other hand, contesting this whole dynamic are the menstruant's kin, who have no interest in allowing the outcome to be decided by naked sexual conflict between outgroup males. Their interest lies in retaining control over the menstruant, preventing any outgroup male from successfully privatizing her. That way, they can ensure that additional mating effort expended by outgroup males accrues to themselves as a coalition. If all equally 'paint up', constructing the menstruant as inseparable from themselves, then every outgroup male can be fed the illusion that his current partner is imminently fertilizable. In this way, success in turning the menstrual signal from a threat into a communal asset can in principle be achieved. The whole strategy may be conceptualized as a form of female 'cheating'. Subverting the 'natural' game of male philandering and inter-female sexual competition, females backed by male kin establish monopolistic control over their own sexual availability, thereby introducing a new game.
An advantage of this 'sham menstruation' model (Power and Aiello 1997; Power, this volume) is that it is archaeologically testable ( Watts , this volume). It also parsimoniously accounts for the evolutionary emergence of initiation ritual (Van Gennep 1960) as the key institutional mechanism for generating and perpetuating the uniquely human domain of counter-reality or 'symbolism'.
The term 'counter-reality' is here used to mean reality inverted or turned upside-down. We may now see how a strategy of menstrually linked sexual and political counterdominance (cf. Erdal and Whiten 1994) would by its internal logic have produced such an effect. Chimpanzees who display the 'female' sexual posture of submission to males as a 'token of respect' (Goodall 1986: 129, 360) are not turning the world upside-down. By contrast, anatomically modern human females who resisted philanderer males, establishing such resistance as an evolutionarily stable strategy, may well have started a social revolution while constructing a symbolic domain at the same time.
Non-human primate females signal 'no' very simply, by displaying sexual lack of arousal or interest. An anoestrous female chimp has no problem in keeping males at bay. Her body itself sends a clear message, and males are unlikely to be interested. Human females, however, have developed continuous sexual receptivity, and the biological human male is liable to 'read' the corresponding signals as indicating 'possible yes'. This confronts women with a rather special challenge. If they are to signal an unmistakable 'no', this cannot be 'left to nature'; deliberate measures may have to be taken.
Signalling 'yes' involves an indexical display of individual sexual identity, fertility, readiness, reproductive value and so forth. A moment's thought will clarify why signalling 'no' in the human case would have generated the opposite — communal 'counter-reality'. The key point is that for a coalition of human females to signal 'no' must logically be to reverse the normal body-language displays indicating 'yes'. To see what this entails, let us take the case of a female chimpanzee in oestrus. In a competitive display, she signals with her rump that she is definitely a chimpanzee (and no other species), definitely female (rather than male) and that she is in her fertile state. We might gloss this as an advertisement conveying three messages: 'right species, right sex, right time': From this we may deduce the signals logically indicative of sexual 'no' or defiance. The alluring display in the human female case should be reversed, so as to read 'wrong species, wrong sex, wrong time'. The female coalition, whenever one of its members is menstruating, should not only blur the distinction between themselves and the menstruant, indicating by artifical cosmetics 'we are all menstruating' (cf. Power, Watts this volume). They should also dance or otherwise signal in body-language 'we are animals' and 'we are males'. Reality, on this basis, will be countered on all fronts.
ORIGINS OF THE SYMBOLIC DOMAIN
The value of this model is that it accounts for the whole pretend-play game — the game of symbolic cultural production and reproduction — which must be established if speech as a subsystem is to work. This game involves sex, kinship and also economics; its premise is that 'rules' operate across the board.
A reality-defining representation is now being staged in direct pursuit of a fitness-enhancing kin-coalitionary strategy of exploiting the provisioning energies of outgroup males. Attempts by such males to fight over, harass or privatize an imminently fertile daughter/sister are resisted.
A young woman's first menstruation now triggers a performance — a public display of her fertility, marriageability and equally her current inviolability and inseparability from her kin-group. Protecting her may mean forming around her a solid wall of resistance. Signalling 'no' to outgroup males involves staging a kind of 'theatre of the absurd' — females posturing as 'male', humans pretending to be 'animals'.
The outcome is a simple form of 'initiation ritual', triggered by the onset of menstrual bleeding, involving coercive monopoly control over the menstruant, constructing 'blood' (real or surrogate) as the ultimate taboo-signal, generating a communal domain of 'counter-reality' — and ensuring that the central reality-defying representation is well respected and defended. Members of the ingroup embrace the paradoxical, 'totemic' representation ('wrong species' etc.) as an expression of their own group identity/inviolability (cf. Durkheim 1912). We would expect outgroup males to perceive the display as deceptive — those supposed 'males' are clearly only females, those alleged 'animals' really human beings. However, since the 'deceptive exploiters' include these males' own spouses and offspring, the victims will have good reasons to accept the underlying message. For them, the point to grasp is that some things are sacred. In the final analysis, 'No' means 'No'. The pretend-play displays which signal this are literally false. Yet they are 'true' on another level — as metaphorical fictions through which communal resistance is expressed. 'Symbolic culture' is now enabling cooperation between camps which might otherwise have been constructed as 'enemies'; such cooperation may be fitness-enhancing, yet in being secured via coercion it is also in a sense 'unnatural' (cf. Chase, this volume).
We have now modelled an 'initial situation' capturing the essence of human magico-religious ritual and belief (cf. Knight 1991, 1997; Knight et al. 1995). On the one hand, there is currently perceptible reality. On the other, ritual performers are insisting on the secondary status of this reality. 'Counter-reality' — a domain in which the sexes merge, 'sacred' blood flows and humans metamorphose into animals — is being vigorously asserted, and for moral reasons accorded higher status. Among the Khoisan, menstrual onset triggers a performance known as the 'Eland Bull Dance' (Figure 12.1), in which the girl herself is constructed as the 'Bull' (Power and Watts 1997; Watts, this volume). Core myths of this kind are not idle fantasies; they have moral, 'sacred' status (cf Durkheim 1912; Fontenrose 1959). Anyone who expresses doubt is clearly not entering into the spirit of the game.
Now that the basic principle of symbolism is established, new possibilities for linguistic evolution are opened up. To maintain group cohesion and communal identity in opposition to the outgroup, full performative display — 'ritual' — continues to be required, the corresponding costly signals of coalitionary commitment serving internally to authenticate a novel system of low-cost tokenistic communication between conspirators (Knight 1998). Speech can be conceptualized as communal pretend-play, which — along one evolutionary trajectory — becomes adapted for specialised ingroup use to the exclusion of outsiders (cf. Nettle, this volume). The very high levels of ingroup trust now established mean that within each ritually defined coalition, discriminable portions of communally standardized pretend-play can be reduced to vocal tokens — 'words'. Instead of meeting resistance, use of such tokens in fictional elaboration finds social support, placing conspirators under pressure to externalize complex trains of thought via extended signal sequences. Mental processes, for the first time, can be rendered transparent via a repertoire of low-cost tokenistic substitutes for shared, acted-out representations. Darwinian selection pressures, in this novel situation, favour those most fluent in handling such tokens, each speaker recursively embedding fictions whose mutual relationships remain represented in the mind as bodily gestures (cf.Johnson 1987). Exapting neurophysiological capacities evolved at an earlier stage for handling a system of calls still heavily embedded in mimetic gesture (Armstrong et al. 1994; Donald 1991), syntactical speech now rapidly evolves.
[photopress:sl_as_pp_fig_1.jpg,thumb,alignleft]Fig. 12.1 'Wrong sex/wrong species/wrong time': Southern San rock painting, Fulton's Rock, Drackensberg Mountains, Natal, South Africa (redrawn after Lewis-Williams 1981: Fig. 10). The image depicts a young woman undergoing her first menstruation ceremony — the 'Eland Bull Dance. The young woman is shown enrobed within the circular outline of her special menstrual hut. In ritual construction, she is both gender-reversed and species-reversed. She herself is the 'Eland Bull; around her dance 'eland cows' playfully engaged in 'copulation' with her. Note the 'eland tails' of the female dancers and the barred penises (indicating ritual sexual abstinence) of the males.
If this model is accepted, the first 'word' in human language betokened not a physical thing, but a morally authoritative intangible. We can put this another way by saying that the founding speech-act must have been contractually effective (cf. Deacon 1997; Rappaport 1979: 173-221). It invoked the most general of all pretend-play representations, at the apex of the ritually constructed taxonomy. If the earliest language-users had been religious in the contemporary sense, that 'ultimate' reality would have been 'God'. While among southern African hunter-gatherers, wrong sex/wrong species/wrong time yields 'Eland Bull' (Power and Watts 1997), in Aboriginal Australia, the same paradoxical negativity yields 'Rainbow Snake' (Knight 1983, 1988, 1991: 88-121).At the deepest level, believers strive for certainty via ritual and liturgical invariance (Rappaport 1979). For this reason, certain core features of the founding signal resist change To this day in Christian belief and iconography, Divinity is paradoxically both human male and sacrificial lamb, his blood ensuring rebirth by washing sin away. In the beginning was 'The Word' — the performative convening of the human symbolic domain.
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From The Evolution of Culture, ed Robin Dunbar, Chris Knight and Camilla Power. 1999.
Edinburgh University Press, Edinburgh, UK. ISBN 0 748 61076 6.
Author ckPosted on 15/09/1999 09/10/2007 Categories Evolution of Language
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text:
San Vincenzo La Costa is a town and comune in the province of Cosenza in the Calabria region of southern Italy.

Geography
San Vincenzo La Costa is a small town made up of villages including San Vincenzo, Gesuiti, Giuranda, Greco, Pallazello. The town is bordered by Montalto Uffugo, Rende and San Fili. It is largely composed of residents who rely on farming existence and finding employment towards larger cities such as nearby Cosenza.

References

Cities and towns in Calabria

redpajama_set_name: RedPajamaWikipedia


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Thanks Diannah, wish I was there now.....I love Mesa Verde.
Artwork showing tourist viewing one of the many Anasazi cliff dwellings at Mesa Verde national Park. World Heritage series artwork.


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Cost effectiveness of...
Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b270 (Published 10 February 2009) Cite this as: BMJ 2009;338:b270
Errata - February 20, 2009
Gerry Richardson, senior research fellow1,
Karen Bloor, senior research fellow2,
John Williams, professor3,
Ian Russell, director4,
Dharmaraj Durai, consultant gastroenterologist5,
Wai Yee Cheung, senior lecturer3,
Amanda Farrin, director and principal statistician (health sciences division)6,
Simon Coulton, reader in health services research7
1Centre for Health Economics and Hull York Medical School (HYMS), University of York, York YO10 5DD
2Department of Health Sciences, University of York, York
3Centre for Health Information, Research and Evaluation, School of Medicine, Swansea University, Swansea
4North Wales Organisation for Randomised Trials in Health, Institute for Medical and Social Care Research, Bangor University, Gwynedd
5Wishaw General Hospital, Wishaw, Lanarkshire
6Clinical Trials Research Unit, University of Leeds, Leeds
7Centre for Health Services Studies, University of Kent, Canterbury, Kent
Correspondence to: G Richardson gar2{at}york.ac.uk
Accepted 15 October 2008
Objective To compare the cost effectiveness of nurses and doctors in performing upper gastrointestinal endoscopy and flexible sigmoidoscopy.
Design As part of a pragmatic randomised trial, the economic analysis calculated incremental cost effectiveness ratios, and generated cost effectiveness acceptability curves to address uncertainty.
Setting 23 hospitals in the United Kingdom.
Participants 67 doctors and 30 nurses, with a total of 1888 patients, from July 2002 to June 2003.
Intervention Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy carried out by doctors or nurses.
Main outcome measure Estimated health gains in QALYs measured with EQ-5D. Probability of cost effectiveness over a range of decision makers' willingness to pay for an additional quality adjusted life year (QALY).
Results Although differences did not reach traditional levels of significance, patients in the doctor group gained 0.015 QALYs more than those in the nurse group, at an increased cost of about £56 (€59, $78) per patient. This yields an incremental cost effectiveness ratio of £3660 (€3876, $5097) per QALY. Though there is uncertainty around these results, doctors are probably more cost effective than nurses for plausible values of a QALY.
Conclusions Though upper gastrointestinal endoscopies and flexible sigmoidoscopies carried out by doctors cost slightly more than those by nurses and improved health outcomes only slightly, our analysis favours endoscopies by doctors. For plausible values of decision makers' willingness to pay for an extra QALY, endoscopy delivered by nurses is unlikely to be cost effective compared with endoscopy delivered by doctors.
Trial registration International standard RCT 82765705
Gastrointestinal endoscopy is a common clinical procedure, and its use is increasing over time. To meet the increasing demand, endoscopy is becoming widely practised by nurses in the United Kingdom.1 There has been little evaluation of the cost effectiveness of procedures undertaken by nurses rather than by doctors.
Consideration of the economics of diagnostic procedures can be complex as the cost effectiveness of the consequent treatment of any discovered condition needs to be considered. Economic evaluations of screening tests often estimate a "cost per condition detected," which is determined partly by the sensitivity and specificity of the test. We focused not on the cost effectiveness of endoscopy itself but on whether or not there is a difference in endoscopy delivered by doctors or nurses. We took a pragmatic approach to the evaluation of this complex intervention,2 in which we assumed that it is the method of delivery (nurse or doctor) that is under consideration, not the intervention itself. We assessed relative cost effectiveness as part of a pragmatic randomised controlled trial undertaken in the UK.3
Study design and interventions
In the cost effectiveness analysis we addressed two issues: the decision about who should undertake the intervention and the level of uncertainty around this decision.4 5 The incremental cost effectiveness ratio represents the relation between costs and outcomes and thus facilitates decision making. We characterised the uncertainty associated with this decision by estimating the probability that nurse delivered endoscopy is cost effective over a range of values of decision makers' willingness to pay for an additional quality adjusted life year (QALY).
The clinical study, of which this economic evaluation was part, was a pragmatic randomised trial in 23 hospitals in England, Scotland, and Wales.6 A total of 1888 patients were allocated at random to either a doctor or a nurse for upper gastrointestinal endoscopy or flexible sigmoidoscopy. We collected health outcome measures at baseline, one day, one month, and one year after the intervention. Further details of the trial conduct, and patient sample and characteristics, are described elsewhere.3 We take a UK National Health Service (NHS) perspective with effects assessed in terms of health gains measured in QALYs. As the time horizon of the study was one year, discounting was not appropriate. We did not extrapolate beyond one year as the study was not powered to detect differences between groups in factors influencing long term health outcomes. We used Bayesian analysis in which the parameters have probability distributions. Thus it was possible, and appropriate, to compute the probability of an event being effective or cost effective.
Data collection and outcome measures
We extracted information on resources used during endoscopy of trial patients from resource time sheets. Information collected included duration of endoscopy, number of patients undergoing endoscopy, staffing, and consumables used (except for therapeutic procedures). The duration of procedures was timed from the extubation of one patient to the extubation of the next.
We obtained data on resource use after the endoscopy from examination of patients' medical records and patients' questionnaires administered at baseline and 12 months (table 1)⇓. We estimated the cost of the intervention from data on the duration of intervention from the clinical trial multiplied by figures for the cost per minute (for doctor or nurse) estimated from Netten and Curtis.7 Table 2⇓ shows unit cost estimates in 2002-3 prices.
Details of resource use data and unit costs
Unit costs of resources used
We used the EQ-5D instrument8 to measure patients' health states and to ascribe values to those states. This instrument measures health across five dimensions (mobility, self care, usual activities, pain and discomfort, and anxiety and depression). Patients have three possible responses (no problems, moderate problems, or severe problems) for each of these dimensions to reflect their perceived their health states. This puts each into one of 245 mutually exclusive health states (the 243 states arising from the EQ-5D, plus unconscious, and dead), each valued on a scale from 0 (representing death) to 1 (representing perfect health).
We converted all EQ-5D scores to "utilities" through a tariff derived from a representative UK population sample.9 We compared mean QALYs generated in the two groups over the 12 month period. We plotted utility at baseline and subsequent points and calculated the area under the curve to estimate QALYs gained (or lost) by each patient. This reflects the fact that the QALY is the product of time and utility10 and assumes that changes in utility over time follow a linear path.11 We adjusted these estimates for baseline EQ-5D as recommended by Manca et al12 and included sex and age as covariates. In a subgroup analysis we separately considered the cost effectiveness of sigmoidoscopy and oesophagogastroduodenoscopy.
Resource use and EQ-5D data were missing in several patients, with some missing both. For analysis we assumed that data were missing at random. We used two methods to impute missing data. For EQ-5D, we used the last value carried forward, as patients' last score is likely to be the best predictor of the missing value. For resource use we used regression to impute missing values from age, sex, and EQ-5D scores.
Traditionally, cost effectiveness analyses estimate incremental cost effectiveness ratios from mean differences in costs and effects between treatment and control groups, and 95% confidence intervals from the independent samples t test. As interpretation of incremental cost effectiveness ratios derived from more than one quadrant of the cost effectiveness plane is problematic,13 we calculated net monetary benefit14 for each group from trial and imputed data.15 To calculate patient specific net monetary benefits we multiplied each patient's QALYs by the assumed maximum value of a QALY and subtracted that patient's costs. We used these patient specific net monetary benefits to derive cost effectiveness acceptability curves and estimated the aggregate benefit from the equation:
where λ is the decision maker's maximum willingness to pay for a QALY. For example, if treatment A has a mean cost of £100 000 and generates a mean of five QALYs with a QALY valued at £30 000, then the net monetary benefit associated with treatment A is £50 000 ((5×£30 000)−£100 000).
Thus the net monetary benefit depends on the value of the QALY, and analysis shows how sensitive the results are to changes in this value. The uncertainty around the net monetary benefit can estimate the probability that a strategy is cost effective through the cost effectiveness acceptability curve. This is a graphical representation of the probability of an intervention being cost effective over a monetary range for a decision maker's willingness to pay for an additional unit of health gain. We used the values 0 (which assumes outcomes are equivalent or not valued), £1000, £10 000, £20 000, £30 000, and £50 000 as examples of the decision maker's willingness to pay for one extra QALY.
At baseline utility data were missing for 184 patients (10%), either because they did not complete the questionnaire or because one of the items within the EQ-5D was missing. This figure increased to 489 patients (26%) at one month and 576 (31%) at one year. For data on resource use we examined the medical records of 1674 patients (89%); 606 patients (32%) did not report number of attendances in general practice. There were no significant differences in characteristics of patients with and without missing data.
Resource use
Table 3 presents mean levels of resource use⇓. These estimates arise from responders to questionnaires without imputation. For most variables, the nurse based programme increased resource use (table 3).⇓ Endoscopy by nurses was followed by slightly more use of all primary care resources except home visits from general practitioners. In secondary care there were increased attendances at day hospital and outpatient clinics. These differences were small, however, and did not reach conventional levels of significance.
Mean resource use in two groups over 12 month study period
Health states
There was little effect in either group on usual activities or self care. Both groups showed an increased proportion of patients in the least severe pain and discomfort and anxiety and depression groups, and these differences favoured endoscopy delivered by doctors (table 4)⇓. Mobility deteriorated in both groups, with the nurse group again performing slightly less well than the doctor group. These results were consistent with the clinical effectiveness results as measured by the condition specific gastrointestinal symptom rating questionnaire.3 Three of the four factors measured at one year favoured the doctor group, though none of these differences reached significance.3
Number (percentage) of patients in each EQ-5D dimension (health state 1 (best), 2, or 3 (worst)) by group at baseline, one month, and one year follow-up
From these estimates, which included values imputed for missing values, we estimated changes in EQ-5D over one year (table 5)⇓. In turn we used these estimates to generate QALYs.
Mean EQ-5D scores, QALYs, and costs (£) per patient over 12 months by group
Though differences were small, the gain in QALYs was greater after endoscopy by doctors than by nurses. This is partly explained by difference in baseline characteristics, notably the EQ-5D score at baseline. Adjustment for these reduced the difference in QALYs to 0.0153 (95% confidence interval −0.008 to 0.039) (table 5).⇑ We used this estimate in the construction of cost effectiveness acceptability curves, which reflect the finding that EQ-5D score at baseline was higher for the doctor group.
While this difference in QALYs seems to be small in absolute terms, it equates to a difference of five to six days of additional perfect health each year. There are several plausible explanations for the improved QALY scores for doctors. The most likely scenario is that nurses requested more subsequent tests and investigations. Such tests and investigations might have a negative effect on patients' wellbeing and it is possible that this manifested itself in lower QALY scores in the nurse group.
Table 5 shows estimated differences in cost per patient between groups, including the cost of the intervention.⇑ As there was uncertainty around these estimates, the difference was not significant at conventional levels. The intervention cost more in the doctor group because doctors' time costs more than nurses' time. There was little difference in the duration of endoscopy between groups. In addition patients allocated to doctors had slightly higher costs in both primary and secondary care. The differences in costs associated with resource use in primary and secondary care was small. Though in absolute terms there were (slightly) more contacts in both primary and secondary care in the nurse group than in the doctor group, the doctor group was associated with more costly resources, particularly salary costs. Adjustment for total costs for baseline differences in age and sex made no meaningful difference to the results.
Incremental cost effectiveness ratio (ICER)
The doctor group generated 0.0153 more QALYs than the nurse group, at a net cost of £56 per patient. This resulted in an incremental cost effectiveness ratio of £3660 per QALY. There was much uncertainty around these results, and neither the difference in patients' outcomes nor that in costs approached traditional levels of significance. Therefore we used the net monetary benefit approach and generated cost effectiveness acceptability curves.
Net monetary benefits and cost effectiveness acceptability curves
Figure 1⇓ shows the cost effectiveness acceptability curve for values of a QALY between zero and £50 000. Attaching no value to a QALY yields a probability of about 78% of the nurse group being cost effective, implying a chance of 78% that nurses reduced costs. The probability of nurses being cost effective, however, decreases as the value of a QALY increases and as doctors become more cost effective. At a value of £30 000 per QALY, often stated to be the borderline for the NHS, nurses have only a 13% chance of being cost effective. Indeed, for all plausible values of a QALY, doctors are more likely to be cost effective than nurses. There is, however, much uncertainty around this result; the cost effectiveness scatter in figure 2⇓ shows the plots of incremental costs and incremental effects for doctors compared with nurses.
Fig 1 Cost effectiveness acceptability curve
Fig 2 Cost effectiveness scatter
Though this stochastic analysis addresses intrinsic uncertainty, sensitivity analysis is still appropriate to check on methodological uncertainty, specifically uncertainty arising from data imputation and from different forms of endoscopy.
We had complete medical records and EQ-5D data for 440 patients, 227 (51.6%) in the nurse group and 213 (48.4%) in the doctor group, reflecting the distribution of patients between groups in the full trial. Most missing data omitted a single cost or a single EQ-5D dimension at baseline or follow-up. The resulting estimates were similar to those with imputed data: doctors cost £40 more than nurses (−£148 to £231) but generated 0.021 more QALYs (−0.02 to 0.06). This yields an incremental cost effectiveness ratio of £2060, lower than with imputed data. The smaller sample, however, leads to more uncertainty: the probability of doctors being cost effective never exceeds 84%, whatever the value of a QALY.
Sigmoidoscopy v oesophagogastroduodenoscopy
Sigmoidoscopy showed an incremental cost effectiveness ratio of £2600 per QALY for doctors. Oesophagogastroduodenoscopy cost relatively more for doctors, resulting in a higher ratio of £7850. Both ratios, however, would be acceptable for most reasonable values of a decision maker's willingness to pay for a QALY.
Principal findings
Patients undergoing endoscopy carried out by doctors gained 0.015 QALYs more than those treated by nurses, at an increased cost of around £56 per patient, yielding an incremental cost effectiveness ratio of £3660 per QALY. Doctor delivered endoscopy would therefore seem to be acceptably cost effective. The analysis also suggests that, for most reasonable values of a decision maker's willingness to pay for an additional QALY, endoscopy delivered by nurses is unlikely to be cost effective compared with endoscopy delivered by doctors based on the evidence of this single trial analysis. There is considerable uncertainty around these estimates, which indicates that further research might be needed.
We used a randomised trial to compare the cost effectiveness of doctors and nurses performing endoscopy. There were missing data both on resource use and patients' utility. While imputing these data is not ideal, the results of that imputation are robust, as analysis limited to complete cases yields similar results. The study lasted only one year, though there is potential for later effects in this population—for example, missed diagnoses. A longer trial would be ideal, but the similarity of immediate and delayed complications between nurses and doctors suggests there is little difference in their long term performance.
It is possible that the use of the EQ-5D and the resulting estimates of QALYs are not sensitive enough in these patients to identify differences in their health related quality of life. The results of our economic analysis, however, are similar to those of the clinical analysis in that there was a non-significant effect in favour of doctors.
Hence the QALY gain was greater one year after endoscopy by doctors than by nurses. This is despite patients being more satisfied with endoscopies performed by nurses. This does not imply inconsistency, as short term gains in satisfaction probably reflect differences in process, while medium term gains in quality of life reflect patients' perception of outcomes, perhaps in the form of the accuracy of the procedure and their confidence in the results.
Nurse endoscopists might not have reached "steady state" in experience and confidence. As their experience grows, they might become more confident and therefore order fewer follow-up tests. The higher frequency of tests and interventions in the nurse group, however, might reflect intrinsic differences between the professions in terms of attitudes to risk.
Meaning of the study
Though there is debate over the appropriate NHS threshold cost per QALY, Rawlins and Culyer16 argue that the National Institute for Health and Clinical Excellence would be unlikely to reject a technology with a cost of between £5000 and £15 000 per QALY on grounds of cost effectiveness. On the evidence of this trial, therefore, doctor delivered endoscopy seems cost effective.
This result might surprise some as upper gastrointestinal endoscopies and sigmoidoscopies by nurses cost slightly less than doctors and the difference in health outcomes is small and does not reach traditional levels of significance. Our economic analysis estimates the probability of cost effectiveness from the uncertainty around the estimates of costs and effects, rather than discarding differences that do not reach "significance." Hence this methodological paradigm leads to a different interpretation of our results from that adopted in the clinical effectiveness paper.6
Interpretation depends on the paradigm chosen and the factors under consideration by decision makers. Classic statistical inference fails to reject the null hypotheses that there is no difference in effectiveness or cost effectiveness between endoscopy delivered by doctors and nurses. Policy makers might therefore view nurse endoscopists as an acceptably safe and effective way of changing skill mix in health care, releasing medical resources and increasing the role of nurse specialists. In contrast with the classic statistical approach, economic inference in this context makes decisions by comparing the estimated cost per QALY with a threshold equal to the most that a decision maker would pay for a QALY. In this trial this leads to the conclusion that upper gastrointestinal endoscopy and sigmoidoscopy delivered by doctors would be cost effective at a typical threshold. Bayesian analysis goes further by estimating the probability that the intervention is cost effective in the sense that the estimated cost per QALY exceeds a given threshold. In this trial this form of analysis leads to the conclusion that the average doctor endoscopist has a probability of 80-90% of being more cost effective than the average nurse endoscopist at commonly used values of willingness to pay for a QALY. Policy makers or hospital decision makers pursuing efficiency alone would therefore choose endoscopy delivered by doctors.
The choice of skill mix in endoscopy might be influenced by factors other than cost effectiveness, such as affordability, staff shortages, and access to health care, all of which enter into policy decisions. At the start of this trial there was concern about shortages of medical staff but, after the expansion of medical schools, concerns shifted to surpluses and potential unemployment of junior doctors.17 Endoscopy delivered by nurses, in the current state of their training and experience, is unlikely to be cost effective compared with endoscopy delivered by doctors. As nurses grow in experience over time it will be important to continue to monitor both effectiveness and cost effectiveness.
To meet increasing demand for gastrointestinal endoscopy, nurses are increasingly undertaking both upper and lower endoscopy in the UK
Clinical studies, mainly observational and non-randomised, have established the safety and acceptability of this, but there has been little evaluation of the cost effectiveness
What this paper adds
Though there is uncertainty around the results, doctors are likely to be more cost effective than nurses for plausible values of a QALY
Cite this as: BMJ 2009;338:b270
Contributors: GR was responsible for the design, conduct, and interpretation of the analysis, drafted the paper, and is guarantor. KB contributed to analysis, interpretation, and drafting the paper. JW led the trial team and was principal author of the final report. IR contributed to the design and implementation of the trial and drafting of the paper. DD developed, validated, and applied the method of assessing the upper GI endoscopy video recordings, validated the gastrointestinal symptom rating questionnaire, collected and analysed clinical data, notably from hospital records. WYC validated the gastrointestinal symptom rating and gastrointestinal endoscopy satisfaction questionnaires. AF contributed to the overall design and implementation of the trial and drafting of the paper. SC developed, validated, and managed the main database. All authors reviewed successive drafts of both papers.
Funding: The study was funded by the NIHR Evaluation Trials and Studies Coordinating Centre. All researchers are independent from this source of funding.
Ethical approval: The study was approved by the Welsh multicentre research ethics committee and informed consent was given by all patients.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Gerry Richardson, Karen Bloor, John Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung et al
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Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET) BMJ 2009; 338 :b270 doi:10.1136/bmj.b270
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