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The publication of the Scottish Public Health Priorities2 in 2018 provides an opportunity to consider the future direction of public health as part of Public Health Reform1. How can oral and dental health contribute to the wider public health landscape? This is something that I along with the Consultants in Dental Public Health and Chief Administrative Dental Officers Group in Scotland have considered. In this blog post I want to share some of our key findings and messages.

The risk factors for oral diseases are the same as for other non-communicable diseases

If I mentioned poor diet, excess sugar intake, alcohol and tobacco use as risk factors for non-communicable diseases, what conditions immediately spring to mind? Type 2 Diabetes? Coronary Heart Disease? Cancer? Well in the mind of a dental professional those same risk factors might lead them to consider dental caries, periodontal disease and oral cancer. There is a high degree of overlap in the risk factors for oral disease and other non-communicable and chronic conditions which affect our population. Therefore we can use a common risk factor approach3 to ensure we have consistent messages and exert the greatest influence in our prevention activities.

Dentists are well placed to routinely see a “well” population

In a recent survey4, 73% of adults reported they had attended their dentist in the last year. Many of these patients will be attending for routine check-up appointments with no specific problems or symptoms. Therefore, the dentist might be the only healthcare professional a “well” patient sees for a while, why you ask is this important? Well, this provides a unique prevention opportunity, with dental professionals able to identify risk factors, such as smoking, alcohol intake or diet at an early opportunity and provide evidence based behaviour change advice and support such as referral to stop smoking services. As outlined in the Scottish Government’s Oral Health Improvement Plan5 there might also be the opportunity to explore the possibility of dental teams providing general health checks to aid the early detection of non-communicable diseases such as diabetes.

We have shown that investment in prevention pays

Childsmile the National Oral Health Improvement Programme for children in Scotland was first established in 2006. Every child in Scotland has the opportunity to benefit from Childsmile, from the toothbrushing packs and free flow drinking cups handed out by Health Visitors to all children and the universal supervised toothbrushing programme being offered in nursery schools. There is also targeted provision of fluoride varnish in priority nurseries and schools, and the extension of toothbrushing into some primary schools. Research6 has been able to demonstrate cost savings associated with spending on prevention activities. Within three years the nursery tooth brushing programme was shown to have recouped its annual expenditure through savings on actual and anticipated dental treatments. Indeed the programme was recently recognised by the EU Commission as an example of public health best practice7.

We still have a long way to go

Over the past 10 years, oral and dental health professionals, along with our varied range of collaborators have made huge improvements in the oral health of the Scottish population. We have high seen significant increases in the percentage of the population registered with a dental practice8 and have decreased the percentage of the Primary 1 child population suffering from dental disease by around 25%9.

However, we still have much left to do. By the start of primary school nearly a third (29%) of children will have dental decay at a level where treatment is required. We still see a huge inequity in the oral health of our population, with those living in areas of deprivation experiencing significantly poorer oral health as well as marginalised groups such as those experiencing homelessness.

Action can, and must be taken to harness existing momentum and build new and innovative actions to address the inequalities we see. Using a common risk factor approach, and recognising the clear cross cutting issues which affect dentistry, oral health and general health will be key. Action on oral health will result in improved health and wellbeing for our population. Indeed, we cannot strive to have good health for our population without improving oral health.

  1. https://publichealthreform.scot/
  2. https://www.gov.scot/publications/scotlands-public-health-priorities/
  3. https://www.ncbi.nlm.nih.gov/pubmed/11106011
  4. https://www.gov.scot/binaries/content/documents/govscot/publications/statistics/2018/09/scottish-health-survey-2017-volume-1-main-report/documents/scottish-health-survey-2017-main-report/scottish-health-survey-2017-main-report/govscot%3Adocument/00540654.pdf
  5. https://www.gov.scot/binaries/content/documents/govscot/publications/strategy-plan/2018/01/oral-health-improvement-plan/documents/00530479-pdf/00530479-pdf/govscot%3Adocument/00530479.pdf
  6. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136211
  7. https://twitter.com/CDO_Scotland/status/1141375479309639680?s=19
  8. https://www.isdscotland.org/Health-Topics/Dental-Care/Publications/2019-01-22/2019-01-22-Dental-Report.pdf
  9. https://www.isdscotland.org/Health-Topics/Dental-Care/Publications/2018-10-23/2018-10-23-NDIP-Report.pdf

Written by Jacky Burns, Specialty Registrar in Dental Public Health NHS Fife. You can follow Jacky on Twitter.

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The Centre for Health and Development at the Staffordshire University and the Faculty of Public Health (FPH) held a hugely successful conference at the University on 26th June. Given the current political uncertainties and the mounting evidence of the public health impacts of austerity on life expectancy and infant mortality in particular, it was perhaps unsurprising that an event on ‘Economic, Environmental and Health Inequalities in a time of Austerity’ attracted over 100 registrations from a diverse range of public health professionals, including consultants, practitioners, academics, researchers, nurses, students and community workers.

These delegates were drawn from key public health and partner bodies including Public Health England, the National Instiute for Health and Care Excellence, Clinical Research Network, NHS, Universities, local authorities, the Illegal Money Lending Team, the Modern Slavery Network and the voluntary sector. This ensured lively, productive and, on occasions, inspirational discussion.

The speakers also reflected the diverse and inter-connected factors that impact on public health as well as representing the key bodies and levers for mitigating them. Keynote presentations from Professors Mark Gamsu, John Middleton and Chris Gidlow together with Dr Jacqui Ashdown set the scene for each session with evidence and experience-packed critiques of poverty, welfare, environment, food, economic development, debt, and housing.

The three workshop sessions were themed around living, moving and economic inequalities and provided delegates with expert detail on issues ranging from homelessness to county lines, mental health to obesity, loan sharking to the bedroom tax and all points between. Speakers drew on each other’s experiences and a particular highlight was a speaker going ‘off-piste’ to share his lived experience. Two of the speakers were recent MPH graduates and presented work from their dissertations with great assurance and to enthusiastic response. All three Q/A sessions were lively affairs and contributed to the learning gained. There is a rumour that one of our FPH Professors was completing his online CPD in real time! Presentations were complemented by displays from NIHR, a Big Local community project, North Staffs Financial Inclusion Group, PHE and the cream of the recent FPH #PublicHealthLooksLike photograph exhibition.

In short a powerful and productive public health day; much learned and much more to do.

Watch this space for news of next year’s event!

You can download the slides from the Conference here.

Professor Christopher Gidlow, Staffordshire University

Dr. Patrick Saunders, Visiting Professor of Public Health University of Staffordshire

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It wasn’t that long ago in 2017 that I was approaching ST5 and worried about getting my first consultant post. Here are my top tips gathered for Consultant job applications during the final stages of Public Health Specialty training.

Think forward

  • In the last 12 months before the end of training, ask for lists of interview questions from recently qualified Consultants. Use these to undertake a personal SWOT (strengths, weaknesses, opportunities, threats) analysis, then develop an action plan linked to your personal development plan and work programme. One of my gaps was working with elected officials, therefore it was better to know this early and proactively seek out opportunities sooner rather than later.
  • Consider what training and courses there are available as you might need to book on early due to demand. I was lucky to attend a deanery funded course ‘preparing for interview’ with Anna Jackson but the FPH also run a similar course. This really helped with identifying what is my ‘unique selling point’ and frameworks for answering interview questions e.g. (Situation Action Outcome Reflect)
  • Look at what courses are available through the Deanery too. My Deanery provided a Consultant Careers Awareness Workshop, Leadership, Resilience and Educational Supervisor Accreditation. I was also able to access political awareness training through the local authority where I was based.
  • The most impact in my preparation in readiness for Consultant interviews and work life was through coaching and mentorship from new Consultants and a Director of Public Health (DPH). I choose a DPH coach who was quite different in ‘type’ to me.
  • Know about what is important to you in a future Consultant job – a career anchors assessment can help with this. At the time I was applying, I knew I needed a post that offered job satisfaction, stability, supported work-life balance (preferably no on-call) and with a main work base relatively close for school drop off and pick up.
  • Sign up to job alerts (NHS Jobs/FPH Jobs/BMJ Jobs/Jobs Indeed/ Public Health Jobs – Twitter), as knowing what types of jobs that have come up recently gives you a sense of what’s out there. Looking at job descriptions and person specifications also help you identify your gaps so you can work on these before you start applying for jobs.
  • Review and update your CV – it will then be fit for job enquiries. I found this HEENW Checklist useful and asked my Educational Supervisor to review my final draft. Identify your referees and make sure they are happy to be named on your CV or future job applications.

Job Enquiries

When you make that initial enquiry, you don’t know who might pick up the phone. On one of my first enquiries, I thought I would be booking a time slot for a future call but ended up directly speaking to the DPH for 30 minutes.

Think about what are you going to say about yourself and what questions you are going to ask. First impressions count, so even though it’s an enquiry, treat it like an ‘informal’ job interview.

It may sound obvious but before you even pick up the phone to enquire about a job make sure you have checked the following: –

  • Job Description and Person Specification
  • Organisational website and twitter
  • Organisation/DPH/Consultant Team through online searches
  • Local Public Health Outcomes Framework and public health annual report

Use your networks to find out more information about the team and location – Public Health is a small world!

Applications

In advance of ‘the job’ being advertised, start preparing your application: –

  • Ask your Consultant colleagues if they would be happy to share any previous applications they have made with you.
  • Prepare a generic application that can be flexed and adapted for different posts, organisations and job specifications.
  • Seek feedback from your coach, consultant and DPH. They all have experience and insight to offer.
  • Double check your referees are still happy and available to give you a reference and let them know that you have started applying for jobs. Reference requests can get lost in busy inboxes or junk mail folders.
  • Always make sure that any application matches the Job Description and Person Specification, plus use information gathered during your enquiry phone call and pre-visit. Make it easy for the recruiting team to ‘mark’ your application with clear layout and headings.
  • Don’t underestimate the time it takes to complete applications – formats vary considerably depending on the organisation and country.
  • It sounds obvious, but if known from the advert, protect the date of the interview in your diary. It’s hard to get an alternative date for an interview, so if you know there is a clash with another important event, let the recruiting team know in advance. If they really like your application, they may try and set another panel date.

Summary

Take control of the consultant job application process through your individual strategic plan.

The biggest preparation that you can do for a job applications and interviews is on-the-job learning, shadowing and experiences in the year before hand. In future weeks I will be sharing a blog on interview preparation.

Be confident as you have passed FPH exams and gained a wealth of experience through training – now is the time to get your first Consultant post! Good Luck!


Written by Hayley Mercer, Screening & Immunisation Lead – Public Health Consultant, Public Health England, North West

You can follow Hayley on Twitter

You may also find this bog from Kathryn Ingold on transitioning from Registrar to Consultant.

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Community cardiopulmonary resuscitation (CPR) teaches people living in the local community the basic skills of delivering chest compressions and artificial breaths until lifesaving defibrillation can take place for people that have suffered a cardiac arrest (their heart has stopped beating). Many causes of cardiac arrest are reversible with the right treatment, but without CPR and early defibrillation people do not survive long enough to receive these treatments. On average only 10% of people who suffer a cardiac arrest outside a hospital setting will survive. This figure more than doubles when the victim receives community CPR(1).

History of CPR

We haven’t always had this valuable skill at our disposal. People have been trying to resuscitate victims of cardiac arrest since the 1500s, with varying levels of success. By the 1800s the accepted method of treating cardiac arrest became surgically opening the chest and massaging the heart by hand(2). The first publicised mention of CPR as we know it today appeared in Journal of American Medical Association in 1961, entitled ‘Closed Chest Cardiac Massage’. The revolutionary new technique was an alternative to the currently accepted technique of open heart massage(3).

Community CPR in the East Riding of Yorkshire

The East Riding of Yorkshire is a predominantly rural locality. Precious minutes can be lost before victims of cardiac arrest receive CPR, making community CPR even more important. The local council is offering free 1 hour drop-in sessions on CPR and defibrillation to their employees and the public, giving people the opportunity to feel more confident about what to do if someone close to them suffers a cardiac arrest be it family, a friend or someone on the street. The events are advertised using the council intranet and Facebook page and have been received very well. 100% of the feedback collected has been positive and all attendees reported improved confidence performing CPR and using a defibrillator. The council also took part in the British Heart Foundation’s ‘Restart a Heart’ day, raising awareness and training around 50 employees in CPR. There is a common misconception that you have to have a qualification to perform CPR on somebody. The truth is that is you have the knowledge, you can use it to try and save someone’s life.

Automated external defibrillators (AEDs) talk you through how to deliver an electric current to restore a person’s own heartbeat. There are over 100 publicly available AEDs in the East Riding of Yorkshire and Hull, a number the council and partners have worked hard to increase(4). When you call 999 the operator will direct you to the nearest AED if needed, and give you the code to open the safety box. AEDs are much less useful when CPR does not take place – something the council has recognised in its efforts.

The Yorkshire Ambulance Service are also working to address this issue with a successful community responder scheme. Community responders are normal people who are trained to provide initial lifesaving treatment and help to bridge the gap until paramedics arrive.

Community responders carry portable AEDs and are often able to reach the people who need them much faster.

Does it work?

chain of survival

The resus council recognises a Chain of Survival for Cardiac Arrest, which includes: early recognition of cardiac arrest and calling for help, early CPR to buy time and early defibrillation to restart the heart. When each link in this chain is strong, chances of survival can rise to over 50%(5), but if one part of the chain is delayed this percentage drops dramatically.

FAQs

‘Is it difficult to do?’

Research has shown that life-saving skills such as CPR can be taught successfully to children as young as 10 years old, whereas younger children aged 4 and above have been shown to be capable of calling for help and operating an AED correctly(1). In fact the Department of Education has plans to add CPR and first aid to the curriculum by 2020(6).

‘What if I hurt them, can I get sued?’

When a person has a cardiac arrest they are effectively dead. You cannot make the situation worse, but you may save their life. Sometimes you can crack a rib when giving CPR, but broken bones will heal and are a small price to pay for your life. No one in the UK has ever had legal action brought against them for trying to help someone by giving them CPR(5).

‘How can I get involved?’

The worldwide annual Restart a Heart Day courtesy of the British Heart Foundation takes place on the 16th of October. Why not raise awareness and join the millions of people all over the world learning CPR to keep each other safe. You can also look out for local BHF Heartstart schemes which run free 2 hour courses across the country. The easiest way to learn about CPR is via the British Heart Foundation website where you can browse their free information and videos.

References

  1. Plant. N, Taylor. K. (2013). How best to teach CPR to schoolchildren: A systematic review. Resuscitation. 84, 415-421
  2. CPR & First Aid Emergency Cardiovascular Care . (2019). History of CPR. Available: https://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp#10. Last accessed 25/4/19.
  3. CLOSED CHEST CARDIAC MASSAGE-P. Safar. Anesth. Analg. -Vol. 40:609 (Nov.-Dec.) 1961.
  4. OpenStreetMap. (2010-2019). Defibrillators in HU postcode area.Available: https://osm.mathmos.net/defib/progress/HU/#11/53.7516/-0.5493. Last accessed 9/7/1
  5. Resuscitation Council (UK). (2019). Frequently asked questions: CPR.Available: https://www.resus.org.uk/faqs/faqs-cpr/. Last accessed 10/5/19.
  6. Resuscitation Council (UK). (2019). CPR Education Campaign: CPR to be added to the school curriculum. Available: https://www.resus.org.uk/campaigns/cpr-education-campaign/. Last accessed 9/7/19.

 

Written by Isabella Price, FY2 Doctor in Public Health, East Riding of Yorkshire Council 

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June was a busy month for the Policy team at FPH. We released our project’s second discussion paper, furthering our investigation into how NHS organisations are responding to or shaping the broader prevention agenda. Thank you to all FPH members and other partners who contributed!

We also released the results of our opinion polling of 310 NHS leaders about prevention – which we think provide a fascinating starting off point for understanding the journey that NHS organisations are on towards (hopefully) a more prevention-led service.

We also travelled to Edinburgh to meet with our Committee of the Faculty of Public Health in Scotland (CFPHS) members and others working in NHS Scotland organisations, NHS Health Scotland, and NHS National Services Scotland to discuss our findings from a Scottish perspective. We received a very warm welcome from the CFPHS Chair Julie Cavanagh and all of the attendees, ensuring the workshop was not only incredibly informative but also very enjoyable.

We covered a huge amount in a relatively short period of time, but here are our initial 5 takeaways from the event:

  • The planned public health reforms are a huge opportunity to make a significant step-change towards a culture of health – Scotland’s public health reforms are striving to address three key issues: Scotland’s poor relative health, significant and persistent health inequalities, and the unsustainable pressure on health and social care services. The ambitious reform programme has already seen the development of public health priorities for Scotland and the development of a new public health body, Public Health Scotland (PHS), is currently underway. There is a commitment that PHS will be an NHS organisation, at least initially and the current NHS public health workforce will continue to be employed by the NHS, but with increased reach/relationships with local authorities and other community partners. CFPHS is broadly supportive of this approach, but recognises the need to maximise NHS contribution to public health while broadening the reach of the public health function. This is the space of the debate at the moment.

 

  • Our opinion polling findings of NHS leaders about prevention only partially reflect the Scottish experience and mind-set – only 6% of NHS leaders who we polled were living and working in Scotland. We were curious to see if our overall results around prevention priorities, barriers to prevention delivery, prevention budgets, and the most pressing issues facing the health and wellbeing of local communities reflected the situation in Scotland. Workshop attendees told us the following main points:
  1. NHS leaders overall who we polled were most likely to say that the NHS should be prioritising the following five approaches to prevention delivery: the systems approach, embedding prevention into routine practice, embedding prevention into clinical and/or patient pathways, reducing health inequalities, and addressing common risk factors. Attendees at our workshop similarly emphasised the need to prioritise the first four of those, but then prioritised ensuring the NHS is a good employer, e.g. by improving NHS staff health and wellbeing over addressing common risk factors.
  2. We also asked NHS leaders to tell us (based on a long-list of potential tax and regulatory measures spanning alcohol, drugs, obesity and food, and tobacco) the policy or regulatory changes that they thought would most benefit the health of their local communities. NHS leaders overall were most likely to choose measures that impacted on the local food environment, with four out of their top five shirt-listed measures relating to that. Participants at our Edinburgh workshop, however, also chose some of the same measures relating to the local food environment, but they also short-listed a measure relating to drug and alcohol treatment. This, they told us, reflected the fact that in Scotland drugs, alcohol, and suicide are the three largest contributors to years of life lost to premature mortality.
  3. They were most surprised (in a good way) that around half of all NHS leaders polled say that prevention is a core or large part of the work in their department. They were heartened by that result, but some wondered whether understandings of what ‘prevention’ approaches or activity actually constitutes is so variable as to render this finding misleading.
  • FPH may need to revisit our definition and understanding of healthcare public health – Interestingly for FPH colleagues working across health services and in education and training, we heard the strong message that the FPH definition of health care public health (as one of the three domains of public health) was not necessarily applicable to the Scottish health system. Unlike in England, in Scotland there is no existing national framework for the delivery or governance of HCPH and the domain is experienced and described differently. Due to the structure of the public health and health system in Scotland, the majority of those working in specialist public health capability and capacity for HCPH are located within territorial NHS Board Public Health Directorates and are often working across all of the domains at once. This workforce is unlikely to find the FPH definition of HCPH useful for their work. They told us that we need to establish better the scope and vision for HCPH in Scotland and strengthen the HCPH role beyond clinical healthcare services. The Improving Services Commission in Scotland is exploring whether or not to describe the function as ‘Population Integrated Care’ instead.

 

  • Colleagues in Scotland agree that better governance of prevention is absolutely critical to supporting a prevention led NHS In our first workshop back in October 2018, stakeholders identified better governance of prevention as a key area that needed to be prioritised if the NHS was to sustainably pivot towards prevention. Scottish colleagues were very interested to learn from the Deputy Director of Healthcare Public Health at PHE East Midlands, Ben Anderson, about his team’s work addressing the prevention challenge and the governance gaps that they’re striving to fill at trust and CCG levels. Colleagues in Scotland spoke of similar challenges around ensuring strategic leadership for healthcare public health across the system (including the NHS, LA, HSCP, education, public sector, voluntary sector, SG policy makers), the need for better coordination and optimisation of data and intelligence, issues incentivising outcomes, and the need for better performance management of essential prevention activity.

 

  • FPH needs to do more support learning across the nations and help our workforce tell a better story – Despite some clear differences and unique challenges, many of the barriers standing in the way of prevention within the NHS are shared, for example: a lack of funding, a lack of understanding of what prevention and more broadly health care public health actually constitutes and their impact, and a lack of data, and service fragmentation. But different places are overcoming these barriers successfully or identifying some of the missing pieces to help other places overcome them. Attendees at our Scotland workshop want to learn more from what colleagues elsewhere are doing. They would like FPH to host more events like our workshop, to bring colleagues working across the UK on similar issues together to learn from one another. There was also a really strong message for FPH ‘to support us to think differently as a workforce’ and ‘develop a more compelling narrative for what the public health workforce does.’ This will help them communicate the value of the public health approach more effectively.

These are just a few of our initial thoughts. But we’d love to know what you think of our papers, findings, and initial conclusions.

Please let us know by emailing policy@fph.org.uk Thank you so much and we look forward to hearing from you soon

Written by Ahmed Razavi, Specialty Registrar in Public Health and member of FPH’s Public Health Funding Project Group.

and

Lisa Plotkin, FPH Senior Policy Officer

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alcohol sig.png

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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