Better Health For All

On April 29th the Faculty of Public Health Special Interest Group on alcohol held its annual learning event. With support from Public Health England and from the Faculty, the event was able to attract national speakers who came to share their work around reducing alcohol related harm.

Chaired by Professor Woody Caan, the event began with a keynote presentation from Dr Amy O’Donnell from Newcastle University, who shared her work on implementation of alcohol Identification and Brief Advice. Although there is good evidence for the effectiveness of alcohol IBA, particularly in the primary care and Emergency Department settings, embedding this into routine practice has proved difficult. Barriers identified included lack of financial incentives to act as levers, GPs being unconvinced that the advice actually changed behaviour and clinicians seeing alcohol as a ‘sensitive subject’.

Amy went on to share her recent implementation science work in the primary care setting. Emerging findings suggest that both patients and GPs are supportive of the delivery of IBA in primary care, but that more work is needed around promoting the benefits of delivering IBA in this setting as well as around improving understanding of the long term health implications of heavy drinking.

We were also joined at the event by colleagues from Scotland. Debbie Sigerson from NHS Health Scotland shared research that has been done to understand the key strategies needed to embed alcohol brief advice, and also shared the count14 campaign that has been put in place to increase understanding of units and alcohol consumption. Debbie also shared progress of a review that is currently underway to determine variation in delivery of IBA across Scotland and to agree what suite of resources are required for public and professional use, ensuring these are fit for the future (e.g. digital first).

Barriers and enablers to delivery of alcohol IBA were also the theme of Dr Ben Rush’s work, with a specific focus on delivery in the ED setting. Ben, a Specialty Registrar in Public Health working with Nottingham City Council, described a project that had been completed with ED staff at a large acute trust. This had identified high levels of staff support for the delivery of IBA in this setting but that achieving this required ongoing staff training. Similarly to what was presented by Amy in relation to primary care, delivery of clear messages to staff about the benefits of delivering IBA in this setting was also raised as an important issue.

The meeting then received an update on the Lancet Liver commission from Professor Steve Ryder, Consultant Physician in Hepatology and Gastroenterology. The commission has been successful in giving liver disease a high profile and in bringing agencies together in a unified approach to reducing morbidity and mortality associated with liver disease. Steve shared recent research on the impact that use of ‘care-bundles’ has on patients admitted with decompensated cirrhosis and also shared progress made by Hepatology Networks around treatment for Hepatitis C.

The final two presentations of the day had a more local authority public health focus. The first was work presented by Dr Emily Walmsley, a Specialty Registrar in Public Health working with Portsmouth City Council. This focused on tackling issues associated with ‘pre-drinking’ through the use of breathalysers by door staff in the night time economy. The evaluation of this innovative

intervention was associated with small reductions in violent crime and ambulance call-outs and also raised the complexity and challenges that are associated with implementing and evaluating interventions of this kind. Professor Paul Roderick then shared another local authority based intervention that has been led by Rob Anderson-Weaver from Portsmouth City Council. This reported on the introduction of a voluntary initiative called ‘Reducing the Strength’ that put in place requirements of retailers that would limit sales of high strength beers and ciders. More than half of off-licences supported the initiative and it was concluded that it had reduced availability of high strength beer and cider. Issues were raised around evaluating wider health and social impacts and also the long term sustainability of this and similar voluntary schemes.

This learning event built on our 2018 event that was around alcohol licensing and we will be running a further event in 2020 on another key issue relating to reducing alcohol related harm. Anybody interested in joining the SIG can contact either Jane Bethea (jb518@le.ac.uk) or Catherine Chiang (catherine.chiang@ggc.scot.nhs.uk). Copies of slides from the event are also available through either Jane or Catherine.

Written by Dr. Jane Bethea FHEA FFPH, Associate Professor of Public Health, Leicester Medical School, co-Chair FPH Alcohol Special Interest Group

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The blood which has disappeared without leaving a trace isn’t part of written history:
who will guide me to it?

It wasn’t spilled in service of emperors -  it earned no honour, had no wish granted.

It wasn’t offered in rituals of sacrifice -  no cup of absolution holds it in a temple.

It wasn’t shed in any battle -  no one calligraphed it on banners of victory.

But, unheard, it still kept crying out to be heard.

(Faiz Ahmed Faiz writing after the 1965 Indo-Pak war)

In the aftermath of the Pulwama attack in February 2019 that martyred over 50 Indian soldiers, one of the authors happened to have been caught up in the ensuing conflict between India and Pakistan and could not return to the UK. This was because the airspace was closed and all flights grounded due to security concerns on both sides of the border. The incident gave us an opportunity to observe and reflect on the situation, the nature and ideology of war, the history, the current political landscape, the state of politics globally, the role of the media and the cost of conflict.

This recent episode was like the trailer of a blockbuster war movie. The author witnessed blackouts, the feeling of fear, the emotions of hunger for victory and blood, the sounds of fighter planes patrolling the skies, all being drummed up and whipped into a sense of frenzy by the incessant reporting of the media that was often biased, provocative and irresponsible. Amidst the turmoil, voices of sanity by those who could foresee the implications of destabilising the region, were being drowned on either side of the border and the reverberations echoed globally. There was also the realisation of how much power the media holds over the public and how easy it is for human beings to defy logic, and so easily become ensnared and enticed to adopt ‘copycat’ violence within a short span of time, much as occurred during the 2011 English riots.

The Changing Nature of Warfare

Nelson Mandela likened violent conflict to a bonfire, the ingredients of which are needed only to light a spark, that then has the potential to spread from nothing to something that could become uncontrollable. However, conflict and violence involve choice, but a bonfire does not choose whether to burn. The reason people engage in conflict and war is rooted in a common system of beliefs and values, the defence of which is seen as of foremost importance and legitimacy.

The shifting nature of ‘warfare’ has meant that wars are no longer being fought on the battle-field with guns and horses, but in the minds of civilians. Here, media is sovereign, both the judge and the jury. In this new era of social media, fake news and increasing xenophobia, combatting divisiveness has taken a backseat. The media is not always neutral and, in some instances, can be an active participant in crises since they can profit from sensationalising disaster. This, in turn, has meant that they are often responsible for shaping public belief and attitudes.

When we come to the case of India and Pakistan, we see states that exist on the basis of religion and political ideology. Even though there is more that unites than divides, harmony does not overrule the fervent nationalism that often teeters just on the edge of extremism. The question of whether this was a ‘Partition’ of the soul of one nation, or an ‘Independence’ from the colonial forces of the British Raj is not debated in the current discourse: rather, the struggle is always to establish points of contention to gain political control, after which an escalation of conflict and the loss of life becomes inevitable. The ideology of war here was born when communities were grouped on the basis of religious identity and political representation; when people “stopped accepting the diversity of their own thoughts and began to ask themselves in which of the boxes they belonged”.

The Ideology of Kashmir

In 1947, Cyril Radcliffe submitted the Partition map with a boundary line drawn between what is now India and Pakistan, just 5 days before the date of the two countries’ independence in August. Little did he know, that for the next 70 years, that line would be the centre of contention, conflict, and the largest mass migration in human history. Lord Mountbatten’s desire to prove himself worthy of his new position as Viceroy of the ‘Jewel in the Crown’, combined with his commitment to the new Labour government in Britain regarding Partition, meant that the process was rushed. Astoundingly, many states had not even decided on whether they were to join India or Pakistan until after that fateful midnight in August. Kashmir was one of those states.

The princely states could either remain independent or accede to one of the new countries. At the time, Hari Singh, the Hindu ruler of the Muslim-majority kingdom of Jammu and Kashmir, initially chose to remain independent. However, in October 1947, afraid of losing his crown to invading Pashtun forces, he signed the Instrument of Accession to India. The two countries promptly went to war, which ended with a defacto border, the Line of Control, that has been witness to much violence since. In the following years, two more wars were fought, each with larger consequences than the last – in 1965, over 3000 Indian soldiers and 3800 Pakistani soldiers died, and in 1999, during the time of the Kargil War, over 2000 people died on both sides of the border.

The Cost of War

Many lives have been lost in this conflict over the years. Homes, families and entire communities have been destroyed and devastated in the wake of the erupting violence, much like a volcano that becomes dormant but never ceases to rumble.

The Partition of India and Pakistan in itself was a humanitarian disaster. Over 2 million people died, and 14 million were displaced. Entire communities were destroyed, villages were razed to the ground, and all that remains of the memories of an entire generation is ash and smoke. To this day, despite the ongoing refugee crises all over the world and the War on Terror that has wreaked havoc on the Middle East, the Indo-Pak Partition is still the largest mass migration in human history. This communal violence ripped a hole in the fabric of colonial society, and the hole has only grown bigger and more divisive since 1947.

Internal violence has been unprecedented, and external forces are constantly forced to intervene to establish peace, or whatever form of peace they can maintain. The divide runs much deeper than the physical border which divides the two states as families and communities have been split. Enforced or involuntary disappearances of people occur, and human rights are violated and abused. Unlawful killings, sexual violence, kidnappings and injuries abound with no recourse to justice for civilian populations.  Although highly underreported, official figures report that 9,042 people were injured during protests through injuries sustained from the use of bullets, metal pellets and chemical shells in Kashmir between July 2016 and February 2017 and this is just a snapshot over a short period of time. The first ever UN Human Rights report on Kashmir called for international inquiry into multiple violations and stresses “an urgent need to address past and ongoing human rights violations and abuses and deliver justice for all people in Kashmir, who for seven decades have suffered a conflict that has claimed or ruined numerous lives.”

According to the World Bank and Nation Master, there are only 0.9 and 0.7 hospital beds and 0.6 and 0.7 physicians available per 1,000 people in India and Pakistan respectively. In nations where health indicators are so poor e.g. the life expectancy at birth is 68 and 66 years and the infant mortality rate is 38 and 67 deaths per 1000 live births in India and Pakistan respectively, one questions how the two nuclear states can even envision to go to war when their citizens face such poor health outcomes and mortality rates in peace times!

The damage does not just stop at physical health. A 2015 Medecins Sans Frontieres (MSF) study covering all the districts of Kashmir between 1989-2005 show the burden of conflict on mental health. During this period approximately every 1 in 10 Kashmiris reported suicidal thoughts or suffered from severe depression and a fifth of the Kashmiri adult population was estimated to live with post-traumatic stress disorder (PTSD) symptoms. On average, an adult living in the Kashmir Valley had witnessed or experienced 7.7 traumatic events during his/her lifetime of which 93% followed conflict-related trauma. The high reporting of physical symptoms reflected the more common somatic manifestation of mental distress in the Kashmiri population.

In addition, the various costs are not just limited to the inhabitants of those two states. The recent conflict of spring 2019 gave us a simple teaser of the direct and indirect astronomical costs that ripples of conflict can generate, even without full-fledged war. It also demonstrated how the consequences are not limited to geographical borders. For example, over 800 international flights use the India Pakistan airspace daily. Hence, the two countries were not the only ones affected when India and Pakistan shut down the airspace for inbound, outbound or any international flights flying over their airspace and thousands of people were either re-routed or stranded. In an increasingly global world, the consequences of this has huge knock-on effects on the international, regional and local resources, economy and trade. Thus, what happens in one part of the world has an impact on another part of the world, be it disease, conflict or politics.

Conclusion

In the post-Partition world of South Asia, Kashmir represents the unattainable, the ‘ultimate prize’. Both sides are willing to use the ideology of this land, its people and their resilience in the face of hardship as a call to arms whenever tensions between India and Pakistan escalate. Nowhere, however, are Kashmiris and the victims of the ensuing violence asked for their opinion, just as they were denied a right to decide their fate in 1947.

In conclusion and looking to the future, various groups can enact changes that will contribute to easing IndoPak relationships. There is no greater contention in the history of these two countries than the Kashmir issue – two wars have been fought, each undecided and each a loss for both sides.  This has not been simply because territories were lost, or lives were ruined; instead, the Kashmir issue has been a failure for both bordering countries because, on the levels of humanitarian principles, both countries have failed to put the people of Kashmir above their own political agendas.

The dangers of an irresponsible media should not be underestimated – without a reliable and neutral distributor of information, alongside thoughtful analysis, it is difficult to predict the common man’s reaction to violence. The focus and aim of reportage should not be to produce sensational headlines to clickbait readers and viewers, since this will only incite anger and turn Indian and Pakistani audiences against each other. Those readers aware of the dangers of poor reportage should campaign for responsible media coverage. If enough people put pressure on social media and mainstream media providers for fair and unbiased evidence-based reporting, there may yet be a shift in reporting tactics.

Instead of focusing on differences, media outlets should be tasked with drawing attention to commonalities to remind Indians and Pakistanis of a singular heritage, and the many reasons to repair relationships. It is important to remind both sides that, should war be waged, it will be waged against men and women just like them. In fact, only two generations ago, they were neighbours and citizens of the same country. This shared sense of belonging and history should mean something, and it is this aspect of identity that the media should draw attention to, to encourage efforts of peace and neutrality rather than fan the flames of war and dissent.

Furthermore, both countries should fund research that tries to better understand the role of ideology in conflict and how it might be used to inform conflict management and resolution. If it was possible to understand the impact of societal inclusion, norms, morals and religion on violent tendencies, perhaps it would be easier to see what could be done to target these. For example, studies suggest that modifying perceived transformative experiences of groups of people that feel oppressed or threatened and reducing that common perception of oneness or shared self-defining experiences can help in resolving conflict. Other studies on the cognitive drivers of conflict show that immediate cognitive pathways (hot cognition) can stimulate strong feelings linked to identity (ethnic, geographical) and associated political attitudes. The question, therefore, is that is there a role then for cognitive ergonomics to support the human mental processes of perception, attention, reasoning and decision-making to rationalise war and violence?

The final group that can help install long-lasting and positive change is the international community. Multilateral forums can provide legal and diplomatic pressure as well as a balanced and neutral opinion. It should be stressed, however, that international interest groups have in the past used tumultuous Indo-Pak interactions to further their own interests, and this issue is too dire to allow this mistake to be made again. International bodies ought to act as fair advocates and be reminded of their own responsibilities to prevent global violence through mediation and de-escalation.

The naked passion of the self-love of Nations, in its drunken delirium of greed, is dancing to the clash of steel and howling verses of vengeance.

The hungry self of the Nation shall burst in a violence of fury from its shameless feeding.

For it has made the world its food.

(Tagore, Nationalism (1917:157))

Written by

Dr Samia Latif, Consultant in Communicable Disease Control, Public Health England. Assistant Academic Registrar and member of the UK Faculty of Public Health’s Global Violence Prevention and Pakistan Special Interest Groups

Ms Fatima Naveed, MSc student of International Development & Humanitarian Emergencies, London School of Economics

Dr Jharna Kumbang, Consultant in Communicable Disease Control, Public Health England

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