On ‘social diseases’

Using examples from contemporary social and medical anthropology, critically assess the following review of Briggs’ book: “Cholera has always been regarded as a social disease. It is vastly underreported. Countries do not like to report it because of its commercial impact – they prefer to blame it on their neighbors – and because of variations in the definition of a case. The authors recognize this problem but offer few helpful suggestions. Rather, they criticize administrators, health care deliverers, and epidemiologists, and they take a long time to do it.” (Finkelstein)

Early on in his ethnography, Charles Briggs (2003, p.17) outlines his motivation ‘to disrupt the circulation of stories and practices that kill, foster critical awareness of the politics of health and inequality, and support global cooperation and justice’ which sets itself up for critique through Finkelstein’s review that suggests Briggs and his co-authors ‘criticize administrators, health care deliverers, and epidemiologists’ without advocating any practical points. Unarguably, Finkelstein’s assessment could be levied at many industries and persons, for it is typical of human nature to criticise rather than prioritise coordinated action, yet his review is, overwhelmingly, comprehensive. When contrasted with the clear, almost overly simplistic action plan proposed by Paul Farmer (1999) in ‘Pathologies of Power’, Briggs’ ethnography reemerges in a far less positive light, offering extended discursive engagements with cholera and its narration from several viewpoints, but scarce retrospective policy suggestions. As a result, it is intriguing that Briggs’ frontispiece appropriates Cindy Patton (1996) in Fatal Advice for, in many ways, his own explorations of cholera similarly represent a hysteria and ‘individual blame’ culture. The crux of the considerations prompted by this question is that disease; experiences of it and its outcomes, are variously perceived across cultures, peoples, and power structures. Precisely because the variance in fields of reference can become politically and socially charged, it is important to acknowledge difference rather than to attempt to write it away or negate its existence. Indeed, through the school of ethnomedicine one can argue that the definition of ‘disease’ is not universal; its significance and representations vary, and the only way to ascertain these values is to interact with peoples across disciplines, so introducing a spatial and subjective nature to any verbal construct of ‘disease’. Therefore, it is appropriate to use leprosy as a counterpoint to cholera, both considered social diseases that see lexical difference writ large, and broader overwhelming complications of policy approaches and social management.[1]

Indeed, it is fitting to assess definitions because Finkelstein (2003) employs this exact term: ‘variations in the definition of a case’. In order to distil this argument’s assertion that lexical difference at the microcosmic level extrapolates to public health agendas, one can consider the World Health Organization’s (2000) published resource on leprosy which adopts sweeping and inclusive terminology: ‘generally leprosy should not be diagnosed without a definite loss of sensation’. Extending from the clinical basis, the industry of health is registered through terminology of the ‘commercial’, at once denoting a concern or engagement with commerce: making or intending to make profit. The commerce of health is deeply volatile but pervasive, capitalizing not only on a globalized world economy but also on race, by racializing social constructs. Cholera and leprosy are regarded as social diseases because they exhibit a high incidence among predisposed socioeconomic groups under adverse living or working conditions. An alternative definition as sexually transmitted diseases (pertinent given that leprosy was originally associated with syphilis) captures the social movement of words and experiences of health – or lack thereof (Munro, 1890). What readers of Stories in the Time of Cholera: racial profiling during a medical nightmare (Stories henceforth) are exposed to is a consideration of the different discourses that arise and perpetuate social disease, in particular that of the media – in itself a commercial industry (with interesting lexical punning on ‘an advertisement’ as well as fiscally grounded methodology) – and the injustices that facilitate them. Finkelstein cites a failure of pragmatism in Stories, while Farmer similarly narrates a historical dislocation of justice and public health in the twentieth century. Notwithstanding the judiciousness of Finkelstein’s assessment, it does raise the timeworn debate of nature versus nurture, in itself demanding consideration. The ethnographic nature of Stories does not fulfil the activities Finkelstein expects of it – there is discursive discussion, sometimes delineated through a Western lens, but limited guidance. Perhaps this is based on the nature, or the conflicts of interest of Briggs, with accounts of social disease subject to narratorial framing as suggested by: ‘cholera stories varied widely. Nevertheless, narrators tended to view the epidemic either in terms of its broad social, political, and historical factors or as a medical and epidemiological phenomenon’ (2003, p.8).

Like any experiment or model, Stories is subject to various means and ends as Briggs focuses on the moralizing nature of cholera akin to ongoing engagements with leprosy. Indeed, the modern world’s media and political community encounter great difficulty in reconciling Norway with the existence and persistence of leprosy during the nineteenth-century, because such a social disease remains much easier to narrate through the context of a socio-economically deprecated country such as Bangladesh. Its history in Norway is framed within these terms: ‘leprosy is pre-eminently a disease of poverty – and the hygienic conditions and the economic welfare in Norway have increased considerably in this century. […] There are at present only seven lepers alive in the whole country. Leprosy may therefore be regarded as practically stamped out in Norway today’ (Vogelsang, 1965, p.35). In many instances, it is in the interest of these parties to encourage a racialization of disease, but also a biomedicalization of it as an experiment subject to investigation rather than a public health crisis. Indeed, during decisive years of London-based cholera, Dr John Snow referred to ‘his studies of the South London water supply and cholera as a naturally occurring experiment’ (Paneth, 1998, p.1550). So too, coverage – or otherwise – of these disease trajectories is shaped by timeliness, racialization and veracity. Only a decade ago, in a letter written to the editor of The Times, the problematic terminology of ‘leper’ was raised: ‘leprosy is curable, treatment is free and social discrimination has no place. […] I urge your newspaper to refrain from using the ‘L-word’ (leper) forthwith’ (Sasakawa, 2006). Once again, the lexicon of ‘place’ carries agency, highlighting that writers, forms of publication and circulation all politicize and subjectivise social disease, deciding what to showcase or conceal. The aim of any authorial ethnography is surely to capture what Farmer (2004, p.78) recognises as Pierre Bourdieu’s genius in pulling together a “compendium of testimonies from those the French term ‘the excluded’ in order to bring into relief la misère du monde. […] ‘To subject to scrutiny the mechanisms which render life painful, even untenable, is not to neutralize them; to bring contradictions is not to resolve them’.” Finkelstein appears to appropriately question the extent to which Briggs succeeds in emulating this methodology.

Social diseases are at once something that can be passed around between bodies, cultures, and voices but in each new embodiment or expression they come to represent different things that are empirically, historically and socially constructed. Indeed, Finkelstein’s critique raises Michel Foucault’s (1990, p.140) notions of biopower assessing actors on, and enactments of, change and health on our own bodies and those of others via ‘an explosion of numerous and diverse techniques’. Under this field of thought, power does not solely belong to actors; discourse, institution and regimes of truth produce and reproduce conditions and practices that can be harmful to health. Foucault’s recommendation to look at history less as a linear process of improvement but as an oscillating movement of experience reveals how power is a productive force over society. Biopower acts through knowledge techniques of peoples and subjugates them through ignorance both of historical evidence and constructed disinformation. Indeed, it might be argued that social diseases are ‘plagues’ (Farmer, 1999) widely apprehended even at the lay-person level, but such understanding is inextricably historically bound, and manipulated by local and digital media. Demonstrably, ‘when newspapers and television news programs across the country reported that a massive cholera epidemic in the delta was decimating its indígena residents, the depth of social inequality became deathly apparent. The revelation threatened the racial equilibrium that helped regulate access to power and resources in the region’ (Briggs, 2003, p. 135). Stories tracks the reports and power circulating within the cholera endemic Orinoco Delta of Venezuela between 1992-93 and seeks to highlight variance, revisiting that ‘time’ rather than re-enacting it for the purposes of didactic policy-making. The focus is on explaining health inequalities in the modern, globalized world and so exposing how its peoples can be victimized ‘in the context of local social worlds’ (Janes and Corbett, 2009). Stories cannot be assessed unfavourably for not outlining policy because it occupies a state of representation, exposure and reflection, without extending into the present structure of advocacy. It is useful to here consider the language of nightmare – in itself a social construct and a state of disturbance or non-reality, with shifting connotations and motivations from a thirteenth-century understanding of ‘an evil female spirit afflicting sleepers with a feeling of suffocation’ to ‘very distressing experience’ by 1831 (OEDictionary, 2001).

The move from the space of the book into the populated environment of social disease is taxed, in part through the pervasive literary references which are potentially alienating. Finkelstein’s review identifies the time-dependent nature of reactions to social disease: acute versus chronic, latent versus finite, fear versus memory. Surely Stories’ title is a direct nod to Gabriel García Márquez’s Love in the Time of Cholera, so questioning the role ‘time’ plays for Briggs as author, global health participant or figure of power. Typically, leprosy is figured as an ancient disease – constructed of and about people, while cholera is identified as the quintessential premodern disease (de Sainte-More, 1978) with ‘people who labeled their neighbors as cholera-ridden unsanitary subjects […] often [… catching] cholera’s stigma themselves. Since denigrating images travel so well, medical profiling tends to return to haunt those who use it’ (Briggs, 2003, p.319). Here again, the space of the nightmare and the language of time are registered and recall Finkelstein’s criticism of the taking of a ‘long time’, suggesting an anachronistic methodology for a modern-day publication. But this is in itself problematic. Cholera and leprosy have social understandings that are entrenched in an era that outlined disease etiology without recourse to a biomedical model, often relying on religious and social justification. Indeed, in the case of leprosy it is easy to temporally distance oneself, as its narrative of the ‘unclean’ dates back to Christian ‘times’, but vexedly so, with narration open to bias and questions of veracity surrounding the conception of modern disease. So too, Guy de Maupassant argues for the ‘other’: ‘cholera is something else, it is invisible, it is the curse of the olden days, of times passed, a sort of evil spirit that comes back and that surprises us so much that it haunts us’ (Delaisement and Schmidt, 1959). Of course, such a dismembered approach to social diseases means actively proposing strategies for their management is restricted or willingly overlooked. Which demands a questioning of how these ancient (or, at least, premodern) diseases of cholera and leprosy fit into ‘modernity’ and globalization. It was only two centuries ago that cholera plagued London with the infamous 1854 Broad Street outbreak identified by Snow and that leprosy was endemic in Norway. According to statistics recorded in 1856, the date of the first reliable national census of lepers, the count of a ‘total of 2,858 lepers was reported. Norway had at that time a population of about one-and-a-half million, so that about two per thousand of the inhabitants were lepers indicates a level above the modern-day WHO measure of elimination’ (Vogelsang, 1965).[2]

This identifies a common thread to both Finkelstein’s review and Briggs’ narratives: that of shifting boundaries. The linguistic definition of a ‘case’ is particularly apt to leprosy, which was declared eliminated by the WHO in 2000. This has led to a rise in hidden cases, guilt and blame imposition. This structural power is resonant with Finkelstein’s commentary on Briggs’ criticism of authorities constituting a discourse of blame, highlighting the context that facilitates this vast underreporting of cases. Briggs (2003, p. 21) identifies cholera, leprosy and so-called social diseases as spatial burdens with an associated geography of blame: ‘from the start, the language used to describe cholera was spatial. Defining the epidemic in terms of its location within and capacity to “spread” beyond national borders provided a narrative structure that appeared over and over’. This spatialisation is nationalistic at best, colonialist at worst. Indeed, these diseases have systems of representation that establish blanket associations within the popular imagination such as: cholera is linked ‘with Asia, specifically India’ (Briggs, 2003, p. 26). Meanwhile, Victoria Hislop (2006) demarcates an equally charged spatialisation of leprosy and its interactions in the modern world amongst its citizens: ‘events seem to take place out of the blue that change the course of our lives, but what really determines what happens to us are the actions of those around us now and those who came before us’. Such criticism is a necessary precursor to policy and the forms it takes, which are not, nor should they be, the nature, nor subject, of Stories. Much of this discussion orientates around the nature and functions of identity or personhood and its preservation at local and national levels. At a government level this self-creation is about distancing oneself, for as Erving Goffman (1990) has indicated, leprosy is underreported partly due to its stigmatising potential while cholera creates a culture of fear through its aggressively infectious potential. Linguistically, leprosy is ‘neglected’[3] because of fear of its social and commercial impacts: it is racialized through purblind ignorance and risk. Briggs (2003) seeks to overwrite this via Patton’s assertion that: ‘it is easy to overwhelm what people know with what they fear’. More judicious from Finkelstein would be an assessment that Briggs’ absence of practical solutions attempts to re-frame racialization as denigrating without inadvertently promoting it.[4] Furthermore, the association between health and inequality lies beyond epidemiology in social capital, and the overlap between both biological and neomaterialist explanations. This mixed state is a return to an interim – an attempt to highlight facts in a cogent manner without muddying these with policy-based assessments, a nightmare state that resists a possibilist world to wake into. Indeed, Briggs (2003, pp.3-4) describes the moment at which ‘the unknown disease thrust them [the Riveras] into a nightmarish world of terror and dislocation’.

Prioritising the narration of nightmare in real time, in the lived words of local peoples with cholera and leprosy rather than through the narration of an elitist publication can propel practical, representative and sustainable change. For Finkelstein’s review to be rewritten, it will be necessary to adopt a theoretical orientation that emphasizes shared responsibility and the role of political-economic factors and macrosociological factors (including ethnic conflicts, racism and migration). As Farmer (1999, p.1493) articulates, while ‘it isn’t really possible to merely study the topic [health and human rights] without meaningful and pragmatic interventions; it is important to distinguish between our best analysis and our best strategies’ straddling discourses of biomedicine, public health and social justice. Such developments must be made, for cholera and leprosy continue to influence life even after their ‘power to cause death had dissipated’ and its deadly potential risks becoming little more than a terrible dream (Briggs, 2003, p.298).



Briggs, C., and Mantini-Briggs, C., 2003. Stories in the Time of Cholera: Racial Profiling during a medical nightmare. Berkeley: University of California Press.

Conrad, J., et al, 2007. Heart of Darkness. London: Penguin.

de Sainte-More, G.R.B., et al, 1978. The Story of Troilus. Toronto: University of Toronto Press.

Delaisement, G., and Schmidt, A.M. (eds.), 1959, Contes et nouvelles 1884, Guy de Maupassant. Paris: unregistered.

Farmer P., and Gastineau, N., 2004. ‘Rethinking Health and Human Rights: Time for a paradigm shift’, pp. 73-94, in Gruskin, S. (ed.), Perspectives on health and human rights. Abingdon: Routledge.

Farmer, P., 1999. Pathologies of Power: rethinking health and human rights. American Journal of Public Health, 89, pp.1486-1496. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 4 March 2016].

Finkelstein, R.A., 2003. Book Review of Stories in the Time of Cholera: racial profiling during a medical nightmare. New England Journal of Medicine, [e-journal] 349 pp. 1297-1298. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Foucault, M. (1990). The History of Sexuality, Vol.1. London: Penguin, p.140.

García Márquez, G., 2007. Love in the Time of Cholera. London: Penguin Books.

Goffman, E., 1990. Stigma: Notes on the management of spoiled identity. London: Penguin Books.

Han, X., Silva, F., and Baker, S., 2014. On the Age of Leprosy. [e-journal] 8 (2). Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Helman, C.G. (ed.), 2000. Culture, Health and Illness: An Introduction for Health Professionals. Oxford: Hodder Arnold.

Hislop, V., 2006. The Island. London: Headline Publishing.

Janes, C.R., and Corbett, K.K., 2009. Anthropology and Global Health. Annual Review of Anthropology, [e-journal] 38, pp.167-183. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 12 March 2016].

Jopling, W., and McDougall, A. C., 1988. Handbook of Leprosy. 4th ed. London: Heinemann Professional.

Kleinman, A., 1988. Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books.

Munro, W., 1890. Leprosy and Syphilis. The Lancet, [e-journal] 135 (3487), p. 1436. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 10 March 2016].

Paneth, N et al, 1998. A Rivalry of Foulness: Official and Unofficial Investigations of the London Cholera Epidemic of 1854. American Journal of Public Health, [e-journal] 88 (10), pp. 1545–1553. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 12 March 2016].

Patton, C., 1996. Fatal Advice: How safe-sex education went wrong. Durham: Duke University Press.

Pfeiffer J. and Chapman R., 2010. Anthropological perspectives on structural adjustment and public health. Annual Review of Anthropology. [e-journal] 39 pp. 149–65. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 4 March 2016].

Rabinow P., and Rose N., 2006. Biopower today. Biosocieties. [e-journal] 1, pp.195-217. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 10 March 2016].

Sasakawa, Y., 2006. Letter to the Editor. Leprosy Review, [e-journal] 77 (84). Available through: Lepra Organisation website: <https://www.lepra.org.uk/leprosy-review-index&gt; [Accessed 6 March 2016].

Vogelsang, T. M., 1965. Leprosy in Norway. Medical History, [e-journal] 9 (1), pp. 29–35. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 2 March 2016].

WHO, 2000. Leprosy Elimination. [online] Available at: <http://www.who.int/lep/strategy/faqs/en/&gt; [Accessed: 9 March 2016].

WHO, 2000. Guide to Eliminate Leprosy as a Public Health Problem. [pdf] Available at: <http://www.who.int/lep/resources/Guide_Int_E.pdf?ua=1&gt; [Accessed 6 March 2016].

Williams H. W., 1977. Leprosy – a social disease. Canadian Medical Association Journal. [e-journal] 116 (8), pp.834-835. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Works of reference:
‘nightmare‘ (n.) from Online Etymology Dictionary (2001-2016) available at <http://etymonline.com/index.php?term=nightmare&allowed_in_frame=0&gt; [Accessed 29 February 2016].

[1] Leprosy is often used interchangeably with Hansen’s disease, but the latter is largely archaic in clinical parlance as in Jopling and McDougall, 1988.

[2] Definable as a population prevalence of fewer than 1 in 10,000 people.

[3] Being classified as a Neglected Tropical Disease (Han, X. et al, 2003).

[4] Denigration being a criticism typically levelled at Joseph Conrad’s Heart of Darkness, for example.

Image Credit: CDC Global, Flickr

Malaria and Climate Change

Today is World Malaria Day, which seems as good a time as any to revisit the objective of the organisation with whom I worked last summer. So too, with this year’s Earth Day only recently marked, Roll Back Malaria’s Action and Investment to Defeat Malaria, 2016-2030 publication identifies the ever relevant climate related goal: ‘given that climate change is predicted to increase the range and intensity of malaria transmission, plans to mitigate the effects of climate change are likely to include an increased commitment to controlling and eliminating malaria, and vice versa’.

Weather and climate are major determinants of malaria. The Intergovernmental Panel on Climate Change has concluded that changes in temperature and rainfall will affect the natural habitats of mosquitoes, changing the prevalence of the vector or prolonging transmission seasons (or both) in some areas, and potentially exposing new regions and populations to malaria and other vector-borne diseases [1].

Temperature rises (associated with current rates of carbon emission) of just 2-3 degrees Celsius will increase the number of people at risk of malaria by up to 5 per cent, representing several hundred million people [2]. Further, a World Bank report indicates that by 2050, climate change might threaten some previously unexposed regions of South America, sub-Saharan Africa and China causing a 50 per cent higher probability of malaria transmission[3].

We can turn to country cases to better narrate these statistics and to outline the continuing challenges. A study published in 2014 in the Open Journal of Ecology assessed patterns of climate variables and malaria cases in two ecological zones of Ghana. The researchers suggested that a better understanding of the relationship between rainfall patterns and malaria cases is required for effective climate change adaptation strategies involving planning and implementation of appropriate disease control interventions.

By analysing climatic data and reported cases of malaria spanning a period of eight years (2001 to 2008) from two ecological zones in Ghana (Ejura and Winneba in the transition and coastal savannah zones respectively) they determined the association between malaria cases, temperature and rainfall patterns and the potential effects of climate change on malaria epidemiological trends. The results suggest maximum temperature as a better predictor of malaria trends than minimum temperature or precipitation, particularly in the transition zone.

Climate change effects on malaria caseloads seem multi-factorial. For effective malaria control, interventions could be synchronized with the most important climatic predictors of the disease for greater impact. By comparison, research in Nigeria published last year in the American Journal of Climate Change explored the relation between climate and epidemiology of malaria in the  Port Harcourt Region. The study examines the effect of climate on the occurrence of malaria in this region by matching data from the national meteorological service and hospital records to conclude that the prevalence of malaria is significantly dependent on the increase in rainfall and temperature and recommend regular clearing of drains and the surrounding environment combined with distribution of bednets.

So, what else can be done? The adoption and implementation of a multisectoral approach to defeating malaria remains a priority, with third tier government engagement needed to take the agenda forward. As ever, these narratives and burdens should not solely be addressed on the day in the calendar year in which they are officially marked, but remain continuing hurdles to improved health globally.



[1] Further Reading: http://www.rollbackmalaria.org/about/multisectoral-action-framework/library [Environment and Climate]

[2] Appendix B, Action and Investment to defeat Malaria 2016-2030, June 2015.

[3] The Postdam Institute for Climate Impact Research and Climate Analytics, ‘Turn-down the Heat – Why a 4 degree Warmer World Must be Avoided,’ International Bank for Reconstruction and Development and World Bank, Washington, DC, 2012.

Image Credit: Fabian Biasio, WorldMalariaDay

Displacement, violation and violence in South Sudan

Europe’s migrant crisis has been proclaimed 2015’s news story. But the reality of migrant experience is that it is a trajectory; until long after the displaced person becomes a citizen of a host nation or returns to their original habitus, their state of transition not only persists but also often goes overlooked. This is true of the crisis in the States of South Sudan (SS henceforth), a DFID high priority nation (2012). The etymology of displacement conferring a ‘removal from office’ dates back to the seventeenth century while human rights have a similarly established legacy, denoting those rights that are ‘inherent to all human beings, whatever our nationality, place of residence, sex, national or ethnic origin, colour, religion’ (UN, 1996). The Internally Displaced Persons (IDPs) of SS will occupy the focus of this exploration offset against refugee patterns and associated settlement activity. Through this lens, one can consider a framework in which action is being, or should be, taken to re-establish this population’s rights. It is imperative to recall that the ‘participants’ of crisis are not solely the IDPs themselves, but also the governments and political personnel, the humanitarian aid effort, and the stories of those left behind. Indeed, the lexicon of ‘participant’ and ‘driver’ is perhaps inappropriate, suggesting an agency or performance of choice that does not actually function in this arena, and will be reinterpreted as ‘subjects’ and ‘factors’.

If you were to ask a young subject what prompted them to run away from a familiar situation, they would probably identify the intrusion of an alien party, an activity that manifests itself in the physiological flight response. This simple, but insupportable, vulnerability characterises SS’s IDPs, with conflict the primary factor in displacement. As catastrophe psychologist Dr Richard Sherry (2016) noted in a recent lecture delivered at University College London, it comes as little surprise that those who perceive their lives to be at risk are most susceptible to psychological vulnerability and escapism – it is a symptom of disasters. HART’s work in SS has identified that IDPs find themselves classified as such following experiences of economic or political disturbance. They exist within a conflict zone. Following the referendum of January 2011 with almost 99% voting to secede from the North, SS became an independent country and also the world’s youngest nation. But this newborn peace was soon fractured following conflict at a leadership level between the Blue Nile and South Kordofan States. Since then, the air offensive and ground assaults that characterise the violence in this region have been termed genocide with its associated erasure not only of people but also of entire cultural networks.Screen Shot 2016-02-16 at 00.25.59

This triggered the ‘dis-‘ movement of civilians with some 50-100,000 killed, 1.5 million finding themselves IDPs and a further 546,000 escapees in bordering countries. Of the IDPs, the United Nations High Commissioner for Refugees (2015) suggests that 10% are located in the nine UN Mission sites such as the Doro Refugee Camp but the overwhelming majority live in unidentified, typically remote and hard to access locales. But one must turn our attention to the circumstances that facilitated the renewed violence. The rise of globalisation has indirectly witnessed the increase in displacement and migration patterns. Indeed, Allen et al. (1999) note that ‘globalisation makes it easier to hide, with individuals switching identities and crossing old boundaries’. In the years following SS’s independence, the international community supported the nascent SS with ‘state-building’ while de-prioritising state-society interrelation afforded by ‘nation-building’ which saw an already fragile state fortified from an institutionalised government level rather than adopting a civilian first approach (IRC, 2014). So too, factors of displacement point towards an already vulnerable existence with UNHCR spokesperson Adrian Edwards (2016) remarking that the upsurge in fighting ‘but also growing food insecurity’ were the main reasons for displacement. Indeed, food insecurity following extreme flooding cycles in SS and ensuing violence are the crux of much nation-specific conflict research and findings.

So too, findings identify recalcitrant global public opinion as a key barrier to securing human rights for these IDPs. A peer recently applied for a UK-based ITV (2016) news traineeship scheme and shared one of the application questions, listed as follows: ‘what graphic would you use to illustrate the numbers and origins of migrants recently settling in your patch?’.Screen Shot 2016-02-16 at 00.26.13The gaping box and ring fencing of response to 50 words only exposes the imperative to effect change in this space of interpersonal attitudes towards refugees and IDPs. Otherwise, their respective human rights will go unmet. Indeed, as former WHO Director-General Dr. Brundtland (2003) remarked: ’at the root of the concern for equality and freedom from discrimination in human rights thinking and practice, lies the notion of human dignity’. This challenge of promoting compassion for one’s fellow man, particularly within SS, will not be resolved over the short-term. Instead, education and fairly representative media coverage such as Peter Biro’s photojournalism, must be employed to highlight how art and discourse can raise awareness and commemorate suffering. Demonstrably, political artist Ai Weiwei (2015) advocates ‘we can do a lot if we open our hearts and think philosophically what [sic] refugee is about’. Here referring to the European migrant crisis, his sentiment resonates with the SS conflict and underscores that we have all, at some point in our people’s histories, been migrants seeking humanity, love and safety from host peoples and places. Indeed, cultural eradication must be halted in light of the celebratory possibilities it represents.

In many cases, it has been reported that SS’s IDPs have received neither humanitarian aid nor political commitment. As HART’s Baroness Cox (2014) identifies, to move forward there must be more efficient collaboration between aid and advocacy. Specifically, a coordinated approach is required between the implementing (such as government agencies; Commissioner for Refugee Affairs) and operational partners (MSF, UN-Habitat, UNDP) and HART. But it is not merely a question of political apathy, but also a matter of social security: six humanitarian workers were killed in a refugee-hosting area of Maban County in August 2014 (UNHCR, 2015). In light of this threat to aid, approaches must also seek out those IDPs who are least accessible, so demanding cohesive protection methods and monitoring of the most vulnerable groups as well as the general civilian body. Indeed, according to the IRC (2014), the ‘humanitarian response has had a disproportionate focus on IDPs sheltering in protection-of-civilian sites and camps, who are easier to reach’. However, the immediate priority is to improve emergency structures in all camps and standards of sanitation, education and health. This will require sustainable and continued work with local partners so as to cause minimal disruption or unfeasible input in terms of the local economy and infrastructure.

Thereafter, for SS to be considered by the world’s development community as a nation capable of ensuring the safety, wellbeing and rightful existence of their citizens, they will need to commit and implement a sustainable political solution to end fighting. SS must evidence that it can provide for all people, even those most likely to be hidden, and rely less on the support of the aid effort which must, in itself, be augmented. Camp settlement is not a long-term human rights based solution. Resettlement and fair coverage is.



Allen, T. and Skelton, T. (1999). Culture and Global Change. Abingdon: Routledge.

Brundtland, Gro Harlem. 2003. Statement to the 59th Commission on Human Rights: WHO. [online]. Available at: <http://www.who.int/dg/speeches/2003/commissionhumanrights/en/&gt; [Accessed 1 February 2016].

Burki, S. and Perry, G. (1998). Beyond the Washington Consensus: Institutions Matter. Washington, D.C.: World Bank.

DFID (Department for International Development), 2012. Operational Plan 2011-2015: DFID South Sudan. [online]. Available at: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/67348/south-sudan-2011.pdf&gt; [Accessed January 29 2016].

Edwards, Adrian. 2016. Growing insecurity triggers new displacement in and from South Sudan: briefing notes. [online]. Available at: <http://www.unhcr.org/cgi-bin/texis/vtx/search?page=search&docid=568f9f9d6&query=adrian%20edwards%20growing%20food%20insecurity&gt; [Accessed 12 February 2016].

HART, 2014. Annual report for the year ended 31 December 2014. [online] Available at: <http://www.hart-uk.org/wp-content/uploads/2015/09/HART-2014-Annual-Report-low-resolution.pdf&gt; [Accessed 9 February 2016]. With reference to Baroness Cox.

IRC (International Rescue Committee), 2014. Uprooted by Conflict: South Sudan’s Displacement Crisis. [online]. Available at: <http://www.rescue.org/sites/default/files/resource-file/20141110_IRC_SouthSudan_Report.pdf&gt; [Accessed 12 February 2016].

ITV, 2016. News Traineeship Recruitment for 2016/17. [online]. Available at: <https://itv.taleo.net/careersection/2/jobdetail.ftl?job=1600012T&lang=en&gt; [Accessed 9 February 2016].

Sherry, Richard. 2016. The Psychology of Disasters, UCL Conflict Series. University College London, unpublished.

UN, 1996. Your Human Rights. [online] Available at: <http://www.ohchr.org/EN/Issues/Pages/WhatareHumanRights.aspx&gt; [Accessed 12 February 2016].

UNHCR (United Nations High Commissioner for Refugees), 2015. 2015 UNHCR Global Appeal 2015 Update. [online] Available at: <http://www.unhcr.org/ga15/index.xml&gt; [Accessed 9 February 2016].

Weiwei, Ai. 2015. Amish Kapoor and Ai Weiwei walk in solidarity with world refugees, London. [online]. Available at: <http://londonartreviews.com/2015/09/21/anish-kapoor-and-ai-weiwei-walk-in-solidarity-with-world-refugees-london/&gt; [Accessed 1 February 2016].

Image Credit: CDC Global, Flickr

Our NHS? The Junior Doctor Contract

On the eve of a junior doctors strike day in England we look at the context, current state of affairs, and explain the social media catchphrases you really need to know to inform yourself, and others, of the hands and future of your health. As one future doctor articulates, the on-going action and discussion around the government proposed contract is ‘the latest flash point in the ongoing cold war between two ideologies: health as an unalienable right versus health as a consumer commodity or service.



In 2012, a new contract (pay and hours) was proposed to the British Medical Association (BMA) citing ‘outdated’ and ‘unfair’ current set-ups that date back to arrangements made in the 1990s. Since then, in 2014, talks broke down between the government and the BMA, becoming increasingly fraught since current Health Secretary Jeremy Hunt re-opened them with a view to push the contract through. Although no agreement has been met, earlier this month ministers declared that the contract would be implemented this summer.

In an attempt to move to a “seven-day” NHS, the number of baseline standard hours doctors are expected to work prior to receiving overtime will rise from 60 to 87 hours per week. Hunt has suggested that any doctors who experience a cut in pay would be covered by pay protection, but this guarantee is potentially vexed and has, at any rate, only be confirmed until 2019. So too, this has been called a bribe to pacify current junior doctors, at the expense of future recruits. Of course, it is important to remember that junior doctors already work unsociable hours – including weekends, in fact they form the majority of the staffing at such times, but they are currently fairly rewarded for such commitments with pay bonuses and prioritisation of patient safety.

Discarded placards. Image reproduced with permission from Garry Knight.



‘Junior’ is a loaded and invariably unhelpful word to couple with ‘doctor’. It unwisely suggests professional or chronological ‘-lessness’. In terms of hospital personnel and their structuring, a junior doctor refers to any qualified clinician between the start of their first job post-graduation through their first two foundation (F) years (F1 and F2) until they acquire a consultant position. Which can mean a decade as a junior doctor, or longer, based on their hoped for, or possible, professional development. Of course, pay is stratified across this group based on experience and specialism, but is largely in keeping with pay rises to be expected from public sector jobs.

There are approximately 55,000 junior doctors currently working in England, comprising one third of the medical workforce.

Image reproduced with permission of the BBC.

Image reproduced with permission of the BBC.



This is the course of action taken over one and two day stretches by junior doctors and associated professionals as a figurative stand against imposition of the new contract. Since late in 2015, there have been several 24 hour strikes planned which were later cancelled, or streamlined so that emergency care was not affected. There has been heated debate over the morality of such action, which is supported by the doctors’ trade union (the BMA) as to whether this puts patient lives at risk unnecessarily. The flipside to this, is that any other profession can conduct such industrial action, as per the Underground strikes in central London in the New Year, and that the imposed contract will put incalculable lives at risk, so such preventative activity is, unfortunately, necessary.

The strike days are not, as would be largely warranted, a well-deserved opportunity to have a lie-in. Certainly, there is no judgement passed against those who make use of it to this end, for strategic (a bonus win in the eat-work-sleep-repeat cycle of a junior doctors’ existence) purposes or ideological ones (some question the efficacy of such participatory protest, citing policy as the only game-changer) but on these days, the vast majority of junior doctors will be picketing at their place of work. From first hand experience, I have been woken up by my partner heading back after a day’s leave to Colchester General Hospital on the first morning train from Liverpool Street to join his colleagues at the hospital entrance, and found myself emerging at Russell Square several hours later, to be met by associated parties from Great Ormond Street Hospital and University College Hospital sharing leaflets, information and personal stories.

Image Credit: A Bow-Bertrand

Image Credit: A Bow-Bertrand



The bottom line is that, under the new contract, the vast majority of junior doctors will have to work more unsocial hours for no extra salary pay. Certainly, under the contract due to be implemented, no doctor will be able to, or obliged to, work consecutive weekends without his or her agreement. Although the upper limits of hours doctors will be allowed to work per week will be capped and lowered from its current level, the BMA and many of the professionals it represents have highlighted that having to work more unsociable hours would likely impact patient safety. Indeed, this has been the subject of recent research, with increased deaths dubbed the ‘Hunt effect’.

How would you feel if you had to work a three-day ‘regular’ week from 8am-8pm Monday to Wednesday to then change gear and continue managing health and saving lives on Friday, Saturday and Sunday night of that same week? Harried? Exhausted? Emotionally drained? Dissatisfied? Worried for your own health and those under your care? Isolated, having to miss out on socialising that happens amongst your regularly employed peers over the weekend? All of these, and more.

Being a junior doctor is more than a question of pay and getting the job done. It is a vocation, a craft, and a hard-earned skill: none of which should be stretched beyond reasonable limit.

Image Credit: A Bow-Bertrand

Dame Vivienne Westwood came out in support of junior doctors at strike action along London’s Pall Mall earlier this year. Image Credit: A Bow-Bertrand



The Health Minister launched a pay calculator in late February which offers an estimated breakdown of earnings under the incoming contract and the areas where pay protection may apply. Back in 2015, Hunt suggested the contract offered an 11 per cent pay rise, but junior doctors outline that, in real terms, there would be a pay cut of 26 percent. Furthermore, this so-called 11 per cent rise in basic salary is offered in exchange for increased evening and weekend work.

As a benchmark, the current starting salary for a junior doctor is just below £23k per annum, with additional payments for working unsociable hours and conducting coroner’s reports. At the most simplistic level, as of this summer, when junior doctors move upwards through roles, they will be paid less than the person doing that same position the year previously.



The Sun tabloid is well known for hard-hitting, accurate journalism, ahem, intrigue, scandal, and paper tits. Earlier this year, they ran a typically reliable feature titled ‘Moet medics high life of docs leaders who are heading up NHS strike’ further sub-titled ‘Pics show champagne-swilling lavish lifestyle enjoyed by striking Moet medics’. Following a remarkably thorough Twitter and Instagram stalk of some of the most vocal junior doctors opposed to the new contract, The Sun’s article presented a truly exclusive (read: outstandingly awful. Self-conscious oxymoron) photo diary of doctors having time off, on holidays, at a beach, out for dinner, with a pachyderm. An article to launch a thousand others, junior doctors replied with typically on point, if wearied, humour, flooding this hashtag with images of the quotidian doctor, living it large. A serious case of scraping the barrel. Also associated with #smearthedoctors.



This is a Twitter hashtag adopted by current junior doctors highlighting just how important their work is: real stories, in real time, from real doctors.

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The British Medical Association (BMA) is the trade union and professional association representing doctors and has almost 38,000 members.



Jeremy Richard Streynsham Hunt is a British Conservative Party politician, the Secretary of State for Health, and the MP for South West Surrey. He was previously Culture Secretary and has variously also been described by several terms that rhyme with ‘hunt’. His Wikipedia page offers a lively source of entertainment from witty editors and enthusiast biographers alike.

Image Credit: A Bow-Bertrand

Image Credit: A Bow-Bertrand


So there you have it. It’s up to you to decide whether you support the Junior Doctors’ contract slogan it’s everyone’s fight.


Image Credit: Wire Feeds

Contemporary Activism: a digital world

Readers from the UK and further afield will have either been immediately impacted by, or exposed to, images in the media of neon-clad, placard wielding junior doctors at gateway picket lines to healthcare outlets earlier this month. So too, London regularly plays host to crowds of similar professional and public actors, performing an activity through collective movement and visibility such as last year’s Solidarity with Refugees march.

'Refugees Welcome' at London Rally on 12 September 2015. Image credit: R4vi, Flickr

‘Refugees Welcome’ at London Rally on 12 September 2015. Image credit: R4vi, Flickr.

Protests, engagement with strike movements, demonstrations, ‘sit-ins’ – what are they really about, and what role do they play in shaping legislation and lobbying policymakers in global health? At the most basic level, these are instances of socially enacted politics, with the focus of such activity being a desire to reach a point of debate, challenge or to highlight a cause.

These methods are the original form of activism, first linked with politics in the early 20th century and defined by Sarifa Moola (2004) as the ‘involvement in action to bring about change, be it social, political, environmental or other change. This action is in support of or in opposition to one side of a controversial argument’. The patterns of a rally’s trajectory of mustering, movement and end-point is symbolic of all these forms of action that seek to make change through self-determination and a bottom-up approach.

West Suffolk Junior Doctors Strike. Image Credit: sasastro, Flickr

West Suffolk Junior Doctors Strike. Image Credit: sasastro, Flickr

Indeed, there is comprehensive debate surrounding the impact of such social protests to actualise sustainable change once the social mass and media attention has dissipated. Certainly, the personal sense of social responsibility is often overlooked in the motivations of such activism; in the instance of street protests, participation is heavily influenced by a desire to exercise solidarity as much as to instigate concrete policy change.

In the field of global health, social activism such as collective rallies and awareness events  in countries across the world on World AIDS Day, for instance, are challenging to co-ordinate and are, arguably, devaluing their integral benefit of visually raising the profile of a health issue, cause, or injustice because of their frequency and questionable prospective impact. Hardly a day goes by without a street protest in at least on capital city. Indeed, contemporary activism is witnessing a shift in actors and changing movements.

BT Tower Turns Red For World Aids Day. Image Credit: Jon Curnow, Flickr.

BT Tower Turns Red For World Aids Day. Image Credit: Jon Curnow, Flickr.

In the increasingly globalised, Big Data age, innovative use of social media is becoming increasingly applicable, and effective, in establishing and constructing awareness and advocating for change. Notwithstanding that electronic information dissemination and the passivity of signing an online petition, for instance, can be both unreliable or equivalently ineffectual, there are areas of digital communication that represent powerful and valuable reformative channels.

Digital communication spaces which invite e-participation are clearly identified and outlined in Palgrave Macmillan’s publication ‘Emerging Digital Spaces in Contemporary Society Properties of Technology’ which highlights that these arenas are not just novel gimmicks. Take, for instance, the activism surrounding the youth summit of the organisation ‘Restless Development’ in 2015. At this event, hundreds of International Citizen Service volunteers convened at the Department for International Development at Whitehall, London, which became a hub for interactive digital workshops, Twitter hangouts (collective use of a pre-defined ‘handle’, so augmenting the possibility of trending) and live link-ups and other engagements with the opportunities presented in cyberspace.

Image credit: Palgrave Macmillan

Image credit: Palgrave Macmillan

Pertaining in particular to Twitter, Paolo Gerbudo’s ‘Tweets and the Streets‘ work offers a wide-ranging analysis of the role of this particular social media channel in contemporary activism, reviewed as offering ‘an exciting and invigorating journey through the new politics of dissent, […pointing] both to the creative possibilities and to the risks of political evanescence which new media brings to the contemporary protest experience‘.

This doctrine of direct action can be translated not only to promoting change but also encouraging involvement and snowballing of activity, as seen with the story of Lara Casalotti, a 24-year-old with mixed Thai-Italian heritage who’s shock diagnosis of acute myeloid leukemia saw her turn to digital communications to seek bone marrow donors for her very narrow pool, which has grown into a worldwide appeal.

For Lara, social media’s unparalleled speed of engagement of peoples, minds and resources represents a very personal and surely sustainable approach to promoting awareness and change that can be more valuable than face-to-face contact and street movements in the race to make change in an increasingly time-poor global society.

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Image Credit: Takver, Flickr

The art of giving charitably

If there was one worldly thing I had to associate with the word ‘repulsive’ it would be present gift lists. Many of my otherwise delightful coupled-up friends have nearly seen my non-attendance at their nuptials by sending me an exclusive access code to their top department store digital wish list. Invariably, by the time I get around to accessing said outlet, the only remaining item to be bought is a Nutribullet bundle. Once the temporary amusement that this perfect couple has accidentally included a vibrating, all purpose sex toy on their list has been dispelled, nausea at fuelling their freshly-squeezed diet sets in.

I get why you’d make a gift list: you can consider yourself magnanimous in taking the stress out of the thinking and purchasing for the rich childless aunt you rarely see; you avoid having four tea pot and cup sets. But surely that’s part of the point of present buying: not only at weddings but also for birthdays and national days of celebration. No matter how busy you are, a gift should be representative of a thought and personalised process rather than just another capitalist transaction. After all, if you can’t find a themed tea pot that reflects a joke or memory you share with the happy couple, then you probably shouldn’t be going to their big day. This extends to Secret Santa suggestions. At the behest of my mortified boyfriend, I recently had to remove a comment on social media in response to his group of friend’s annual £5 swapathon in which I refused to participate if we offered a list of suggestions of what we would like to receive  – I mean, it’s not as though your specification will ensure you get a life-changing offering.

A few years ago, I was given a pair of (virtual) charity donkeys for Christmas. Having never written a letter to Father Christmas, I’m used to getting whatever random junk my brother cares to re-gift, or personalised hand-baked offerings from my Mum and while I’m not hard to buy for (and easily pleased) I thought this present reflected a soupçon of ‘can’t be assed’ (get it?). Of course, I was thrilled that my relatives had chosen to redirect the usual gift vouchers into a philanthropic donation, I was just dubious as to whether their money would actually make a difference.

For those who want to ‘give a little back’ or who are just stuck for present ideas, you can now purchase 10 chicks for £10 from Age Concern, a pile of poo from Oxfam Unwrapped for the same fee or even help deliver a baby for £27.50 from Unicef because, you know, noone wants to witness all that mess in person. Sarcasm aside, surely any means of augmenting charitable donations and their contribution to overseas development aid (ODA) should be encouraged (notwithstanding the critique levelled at ODA to developing world infrastructure and local level accountability)? Certainly, increased public and individual level contributions to non-governmental organisations is an important buy-in for the third sector and one they wish to safeguard and expand upon.

Image Credit: oxfam.org.uk

Image Credit: oxfam.org.uk

However, encouraging this form of ‘boxed-in’ philanthropy is problematic. These hypothecated funds associated with specific gifts function as a low-scale equivalent of vertical aid programmes and the 1990s explosion of specific funds such as the Roll Back Malaria Partnership, UNAIDS and the Global Fund to fight AIDS, Tuberculosis and Malaria (which prioritise funding, research and development of specific diseases rather than a more explicitly multi-sectoral, cross-disease burden approach) with associated risks of in-silo working which could, as outlined in this article, leave people behind. Realistically, if your great-aunt annually donates a pair of donkeys on your behalf, you are going to help alleviate a pocket of transportation and access challenges in mountainous Nepal, but will there be enough resources (monetary, skills- and personnel-based) to provide shelter or produce food for these animals?

Luckily, it is unlikely that such ‘thoughtful’ or ‘inspired’ donations go directly to the donkey supermarket, but more probably become absorbed in the donor organisation’s integrated ‘vertical-horizontal’ and collective efforts in locales and populations of focus. But perpetuating a layperson vision of humanitarian aid as a compartmentalised activity grossly undermines the complexity of such altruism; the compounding factors of power and politics, and the bias of perceived and expressed need. Which prompted me to consider: how can we ensure that our money does more good than harm? How can we ensure that its potential is maximised? One such answer was presented by watching Peter Singer’s TED talk about Effective Altruism (EA). Since he delivered this speech in 2013, EA has developed as a worldwide social movement.

Image Credit: YouTube.com

Image Credit: YouTube.com

Most of us will probably have heard of EA, but what exactly is it, and why do I think it might represent a more appropriate and reasoned art of charitable giving? Its official catch line is ‘doing good better’ and fundamentally seeks to answer – through actions and discussion – where and how a small set of individuals can make the biggest difference. It combines both the heart and the head through employing global empathy, critical thinking and open-mindedness to try to choose the path that will make the most difference to global wellbeing. A practical example is as follows: the cost of a guide dog for the blind is $42,000. As an alternative, the cost of performing surgery to correct trichiasis, the blinding stage of trachoma, often costs as little as $40 in developing countries. This surgery is 80% effective. Therefore, sight can be restored to 840 people for the cost of one guide dog, and the guide dog does not restore sight.

There are many ways for both haters of present gift lists, and considered philanthropists, to participate in the EA movement, including through the charity GiveWell,  or the career-focused 80,000 hours which considers how you can make a social impact through your work. Some might argue that wedding gift wish lists practice their own version of effective gifting, but furnishing a newly-weds first home does not really come into the same arena as development assistance, or donkey transportation for that matter. So next time you make a charitable gift, stop and think whether you are just buying into an easy, ready-made option, or whether you are putting the most effort and productivity into your pound.


Image Credit: Randy Stewart, Flickr

Dream Widely: the aspirations of Generation Y

A preliminary briefing on research findings from the multi-disciplinary Millennium Cohort Study (MCS) offered an insight into the aspirations of the Millennial generation in the UK, defined as a sample of individuals born during the year 2000 in Wales, Northern Ireland, Scotland and England. Originally established to assess the influence of early family context on child development and outcomes through childhood, adolescence and into adulthood, the MCS is starting to yield a fascinating snapshot of Generation Y.

Indeed, participant responses to surveys at the ages of 7 and 11 years showed an increase over that time in aspiration or ‘dream’ levels, with a gender disparity with girls citing a proportionally greater wish to work in high level management or traditionally vocational careers (including ‘teacher’, ‘doctor’, ‘vet’). By comparison, ‘sportsman’ was the overall career aspiration for boys at both 7 and 11 years, a trend supported by a 2012 retrospective questionnaire completed by 8000 adults via business-orientated social networking platform LinkedIn. Such findings prompt interesting discussions of whether boys of the Millennium need to be targeted with more wide-reaching career options and role models. To my view, this dream should not be subject to an educational or parenting approach that encourages a move towards more technical careers so devaluing a goal that may appear untenable and unrealistic.

The UK primary schooling system should increasingly seek to offer an ‘education in the school of dreams‘ to re-appropriate Jennifer Lynn Peterson’s phrase and taking inspiration from the recent new wave Japanese early learning system. Child aspirations recorded in the MCS were sub-categorised by ethnicity including children of Asian heritage living in the UK. Asian boys were less likely than their peers to rank ‘sportsman’ as their number one life aspiration, instead citing ‘making money’ as a motivation and ranking associated work positions accordingly (including ‘banker’). However, the recent shift in Japan’s early age education suggests a sustainable adjustment in infrastructure, promoting prosperity and diversity in youth aspiration.

The introduction of compulsory elementary and early secondary education has been critical in sustaining the rapid economic growth Japan has witnessed since the end of World War II characterised by a rigorous ‘heads-down’ curriculum and teaching structure. Indeed, as Peter Cave notes in Primary School in Japan: Self, individuality and learning in elementary education ‘the expectations placed on schools are as high in Japan as in other rich, modern countries, if not higher. Japanese schools have long been entrusted with a major role in the production of “desirable human beings”‘.

However, since 2000 this national classroom attitude has been flipped. Cave concludes that ‘although recent reforms have tended to stress individuality and independence, teachers in [Japanese] primary schools continue to balance the encouragement of individuality and self-direction with the development of interdependence and empathy’. The teachers within this framework are increasingly prioritising an holistic, aspiration-centred approach to studies, with a regular programme of dream identification, setting and exploration. By ‘dream’ we here mean professional and personal life goals. Such an investment in the emotional and life-sustaining role of aspirations (from Latin nominative aspiratio meaning to ‘breathe in’) will surely create a generation of citizens aware of who or what they wish to be in the present and on-going.

Moreover, there is synergy between health and education – if you want to have an influence on one you have to be cognisant of the other. Sustainable Development Goal (SDG) 3.7 (‘by 2030, ensure universal access to sexual and reproductive health-care services, including […] education’), 4.4 (‘by 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship’), and 4.7 amongst others all link education and equity in health. This is situated within a mass of literature on the social determinants of health across the live course, often projected to the year 2030; the end-point of the SDGs and the focus of UCL’s Centre of Longitudinal Studies Countdown 2030 project.

Image Credit: A Bow-Bertrand

Image Credit: A Bow-Bertrand

It can therefore be shown that education is a good vehicle for health improvement globally. There has been a rapid expansion of education across the world since 1970 and health is increasingly part of the core business of schools. In their systematic review of adolescent health and adult education and employment, David Hale et al found that poor health in adolescence predicts 25% to 72% greater odds of lower attainments or NEET (not in education, employment or training). Put simply, health predicts gains in attainments and life chances across adolescence and into adulthood.

Visual source: UNESCO Institute of Statistics

‘Global Education Levels’. Source: UNESCO Institute of Statistics

It could be argued that what appears to be globally lacking is a pre- and adolescent (definable as the the start of puberty to acquiring a stable position is adult society) awareness of the world and aspirations that locate themselves within a non-individual, and even non-ethnographic locus. The MCS recorded scarce awareness of climate change nor career aspirations of ‘environmentalist’ or ‘geologist’. Indeed, even ‘politician’ ranked low on the career list suggesting an introversion of vision and energy. But the picture is not quite so transparent.

Indeed, researchers Helene Joffe and Victoria Zeeb are studying the aspirations of connectedness and autonomy of Millennial [defined here as anyone between the ages of 18-30] city-dwellers. Against the background of an urban environment (with correlating positive and negative influences) they have sought to dispel findings from research such as Twenge, 2013 and the below cover of Time Magazine that suggest Millennials are narcissistic and self-entitled citizens.

Image reproduced with permission from time. Cover photography: Andrew B. Myers

Image reproduced with permission from ‘Time’. Cover photography: Andrew B. Myers

Their work indicates that connectedness plays a key role in Millenials’ envisioned futures and is crucial for their wellbeing. Moreover, they report that simply the act of aspiring to ‘connection’ (familial, companionship, weak ties: ‘relationships involving less frequent contact, limited intimacy and minimal emotional intensity’) is linked to wellbeing. Such data does not bear out studies showing Millenials to be self-orientated. Instead, Generation Y aspire to ‘connection’ in the same manner that non-millennials (cohort X) did, but they are different in forming weak ties in the workplace rather than within the community (these are becoming increasingly harder to form and safeguard within urban lifestyles and aspirations) which may be detrimental to wellbeing in the long-term.

Of course, dreams are not merely the domain of the youth of today, nor are they the reserve of the privileged, developed world persons. I would argue that every human has some aspiration referent whether that be to acquire a safer settlement as Hans Rosling identified amongst the families living in absolute poverty in this podcast, or those who seek to earn a postgraduate qualification. Even Kanye West has dreams. They are the very substance that gives our lives meaning and, sometimes, purpose. Putting this meaning into practice might become more challenging as one ages but at every stage of the life course our mental and physical wellbeing can be embraced through a process of ‘dream’ recognition.

I recently attended a ‘what I wanted to be when I was younger’ themed 25th birthday party. Of the aspirational careers that studded my childhood (figure skater, Post Office sorting officer, lighthouse manager and doctor), the latter loomed overwhelmingly large. Donning my old scrubs and borrowed stethoscope I realised I was typical of the Millennials in having regularly changed my life aspirations during childhood, but I was unusual in initially pursuing medicine as a profession (only 30% of adults are expected to be working in the career area their 7 years old selves identified as number one choice, and the figure is much lower in other studies).

My dreams changed and will no doubt continue to shift and develop. So will those of my fellow party-goers. From clowns to athletes, celebrities to teachers, such aspiration must be consistently celebrated, addressed and, arguably, pursued at regular stages in life development. As Rudyard Kipling advocates in his infamous poem ‘If’: ‘if you can dream – and not make dreams your master’ from childhood onwards, then the next generation of professionals and global citizens will enjoy a healthy self-reflexivity of understanding and ideology.


Image Credit: Airwolfhound, Flickr

Setting Goals: from Vision to Action

Since the release of the Sustainable Development Goals, 2015-2030 (SDGs) in mid September, the ensuing weeks have been studded with discussions addressing how to shape these targets into practicable actions that will effect meaningful change. This month, the annual UCL Lancet lecture invited guest Ms. Amina J. Mohammed (Special Advisor of the Secretary-General on post-2015 Development Planning) to speak on the new universal SDGs for 2030 with the catchphrase ‘from vision to action’.


Cruciform Lecture venue. Image courtesy of A. Bow-Bertrand

What does this emotive punchline really mean? It is here useful to revisit the precursor Millennium Development Goals (MDGs) from which this sustainable development agenda has arisen. Although widely berated for being static and failing to reach imposed standards, the culmination of the MDGs heralded some success stories. Fundamentally they represent the first instance of global partnership at a time when there was no common framework for global health promotion.

Indeed, over the past 20 years child mortality (dying before the age of 5) has been reduced by almost half. Arbitrarily this means about 17,000 children are saved every day. Meanwhile, globally, the maternal mortality ratio decreased by 45 per cent between 1990 and 2003. In terms of a disease specific result, the former World Health Organization (WHO) funded Roll Back Malaria Partnership has identified the fight to eliminate malaria as the cite of great progress. Indeed, between the millennium and 2012, an estimated 3.3. million deaths from malaria were averted due to substantial expansion of interventions and prophylactic programmes.

Notwithstanding these burgeoning successes, the MDGs did not stand the test of time across the board. Over their duration, economic growth demanded reactive targets that accommodated inflation and trend analysis neither of which were implemented at a functional level. More importantly, perhaps, it is important to identify that what the policy-makers of the global community identify as MDG achievements are not necessarily representative of the opinions of country-level governments or civilians.

Any assessment of the MDGs and approach to the SDGs must be, as Sir Michael Marmot remarked upon publication of his latest work The Health Gap: the challenge of an unequal world, ‘culturally relevant’. To this one might add temporality and context dependent. After all, it is tricky to assess the achievements of the SDGs from our current 2015 standpoint. Instead, we must hold them to account in relation to their millennium world inception.

Image reproduced with permission from Bloomsbury Publishing

Image reproduced with permission from Bloomsbury Publishing

The transition between the MDGs and the SDGs is not necessarily clear-cut and there is merit in considering the SDGs as unique goals constructed out of their time and its demands. With 17 goals, one might question whether they are sufficiently specific but, as Mohammed noted, given the many existent worldwide health dilemmas and inequalities this is, in fact, a strongly condensed working pool.

Reproduced with permission from the UN

Reproduced with permission from the UN

These goals increasingly apply to developed countries, prioritising inclusivity of all UN member states and accessing hard to reach populations from the goal-setting process onwards which attempted to hear the voices from every societal strata. The transformative agenda of the SDGs looks at how to reach those most often forgotten while feeding a growing economy. Mohammed suggests: ‘we are not subject to the budget; we are the budget’, and as such we must be agents that simultaneously propel concrete action while protecting human rights.

In spite of the single goal pertaining solely to health (Goal 3: ensure healthy lives and promote well-being for all at all ages), the SDGs are collectively co-dependent, aiming to facilitate human and animal health in our world for the long-term. This agenda is the most ambitious yet, being simultaneously conscious of approaching development through synergistic and interdependent methods while recognising the limitless nature of setting environmental targets (something Mohammed is herself just coming to terms with following her surprise recent appointment as Environment Minister for Nigeria) alongside economic, partnership, and infrastructure aims.

The SDGs are about more than just ending poverty (Goal number 1: end poverty in all its forms everywhere); they are increasingly ‘planet sensitive’. The segue from the MDGs to the SDGs is marked by a question of ownership. No longer is this agenda the elitist property of the government. This time it is owned by the people, with targets of health for all everyone’s very personal business.

Which goals will be prioritised at country-level cannot be definitively predicted. Country governments will focus on laws and policy-making that best pertain to the most pressing or controversial needs of their nation. Local political concerns will always trump the comparatively vague, aspirational non-context specific ideas of the SDGs. This demands a creative engagement in the goals that transcends their terminology and content bounds. Comparably, Mohammed advocates talking about health and how it informs the goals rather than focusing on it as a discipline to which only goal 3 is immediately derivative.

Indeed, the SDGs are novel by responding to the United Nation member states’ express wish to manage things at the domestic level as part of a ‘global village’ which overwrites the divide between the ‘North’ and ‘South’. The SDGs seek to move from vision to action by addressing global economies and the social agenda beyond national borders guided by Secretary-General Ban Ki-moon’s fluid rather than prescriptive agenda which valued context specific goal setting.

The Financing for Development workplan that was agreed at the Third International Conference held in Addis Ababa, Ethiopia considered mobilisation concerns. More than ever before, if the SDGs are to be operational rather than merely aspirational, government expenditure that goes into leveraging the capital economy will need to  be supported by other monetary flows . ‘The financing framework of Addis Ababa is [according to Mohammed] doable’ and will raise awareness of the necessity of smart investment and seeing the SDGs and their achievement as more than just corporate social responsibility.

Mohammed concluded that ‘we have a shared responsibility and a shared future. […] It is about an international justice for peoples. The SDGs are transformative by showing that business as usual  is not possible on the development pathway’.


Mohammed in discussion. Image courtesy of A. Bow-Bertrand

MdM regularly prioritises work and figures that reflect the experience of the humanitarian context. Therefore it is pertinent to ask whether the humanitarian field can be addressed in the SDG 3. This question is still being addressed. The challenge to answering this in practice and conceptually arises from how to mobilise governments at the local level to make achievable change through sustainable action. Country-based planning over the short and long-terms will perhaps indirectly meet or absorb the priorities of the humanitarian context.

However, the most salient take away message from Mohammed’s lecture was that the SDGs must be fit for purpose: able to create an actionable plan for the modern world. To be temporally appropriate, a Data Revolution is an absolute priority. If we say that we do not want to leave anyone behind then we must consider where they are and who they are. Mohammed highlighted that we do not have comprehensive baseline data of peoples or fixed global indicators to measure development. Their acquisition will be essential, and will demand strategic and weighty investment enabling countries to measure their own development at a local level supported by global leverage.

By looking inwards, the vast and often disparate global health community can reflect on success stories and move forward through action, investment, and accountability. 


Image Credit: Nana B Agyei, Flickr.

Health in Conflict Zones

A few weeks ago I attended ‘Heal The Word: Many Disciplines, One Goal’ conference hosted by UCL Medsin. One of the central plenaries was titled ‘Health in Conflict Zones’ which afforded a useful sounding board for thoughts and reactions I have received second-hand from professionals with experience in active and post-conflict areas. Conflict is here identified as any singular or succession of events that threatens the well being and physical or psychological health of a population, whether pertaining to an internal or external cause.


Conference location: The Cruciform building overlooking UCL Main Quad

There were two remarkably insightful responses to this theme from namely:

Dr Ang Swee Chai who asked: ‘who is it that defines [terror and a] terrorist’? Based on her experiences as both an orthopaedic surgeon at St. Bartholemew’s Hospital, London and the conflict zone of Gaza in the State of Palestine, Swee Chai reflected that war is constructed by air (‘bomb the hell out of everyone’) with a secondary wave of territorial invasion. She went further, asking whether it is a doctor’s job to speak up in a conflict situation. One school of thought asserts that health personnel are there to be passive providers, avoiding any self-expression that might jeopardise their ability to provide healthcare and relief aid. She argued that, as advised by the principle of ‘témoignage’ advocated by Médecins Sans Frontières (MSF) amongst others, that yes, they absolutely should.

Based on discussions I have held with professionals engaged in both preventative and crisis relief work, I would concur in most instances because global awareness of the truth and reality of what is going on in notoriously under – or worse, falsely – reported conflict situations, will invariably mobilise greater humanitarian and political action than keeping one’s head down and functioning to the best capacity within a framework of oppression and censorship. Kate Winslet’s performance in Contagion (2011), while remarkable for its artistic performance, is a creative engagement with these often contradictory pressures of vision and action. Swee Chai considered the anthropocentric quality of medical professionals, noting that the future heralds robots and technology that can practically carry out the same technical job, to a possibly better standard, than health professionals currently can. What these artificial doctors will lack is both the human heart and compassion to identify and raise awareness in instances where human rights are violated. 

Dr Ang Swee Chai. Image reproduced with permission from Tarek Charara/Kaleidos.

Dr Ang Swee Chai. Image reproduced with permission from Tarek Charara/Kaleidos.

Meanwhile, ex MSF doctor Dr Ana García Mingo asked when humanitarian organisations should intervene in zones identified with a conflict status. I would argue that any intervention should coincide with a recognition that the health or survival or a specific population is threatened. Importantly, García Mingo reminded us that the first thing that stops after any crisis is preventative care, notably routine vaccination programmes. So too, as Daniel Flecknoe, a former emergency care nurse dispatched by MSF to North Darfur at the end of 2008 (he speaks to MdM in a forthcoming post) identifies, local health professionals and staff that are citizens of these zones are often unfairly overlooked and their efforts receive sparse coverage.

Moreover, these individuals are invariably volunteers rarely receiving monetary compensation for their time and efforts because they are problematically acting within country for a third-party aid organisation. The 2009 film ‘Living in Emergency’ features some of these figures. Focusing in particular on settlements of both internally displaced persons and refugees, Mingo further highlighted the critical difference between these very peoples: across borders and between them and, by extension, the difference in the nature of refugee camps and the access of those who cluster in them to both healthcare (from medicines to vaccines) and technology (Internet connectivity and mobile reception).

'Living in Emergency' (2009). Image reproduced with permission from Doctors without Borders.

‘Living in Emergency’ (2009). Image reproduced with permission from Doctors without Borders.

As will be highlighted in my interview with Flecknoe, provision of healthcare in conflict zones is not as straightforward as applying a metaphorical bandage to temporarily stem the flow of chaos, bloodshed and political unrest. There must be a sustainability to any aid provision, with a careful balance that manages the governing factions of any such crisis while consistently focusing on the bigger picture. This large-scale world view will, in the long-term, safeguard lives even if in the short-term it appears to threaten the acute activity of damage control of lives, peoples and places.

Image Credit: UCL Medsin.