Violent Borders: Border Conflict, Security and the Refugee Crisis

The ideological and physical implementation of borders has become a key debate surrounding the global refugee crisis. In the past decade, forty-thousand people died trying to cross international borders, with deaths along the shores of Europe only accounting for half of these.

At the same time, military-industrial complexes have expanded to further secure and police border zones across the world. The relationship between conflict along borders, security and militarised projects, and the refugee crisis prompts ever more relevant discussion.

I recently went to a talk called ‘Violent Borders: Border Conflict, Security and the Refugee Crisis’ at the Frontline Club in London’s Paddington. This was opened with a presentation by Dr Reece Jones, Professor of Geography at the University of Hawaii and author of a major new analysis of the refugee crisis focusing on how borders are constructed and policed: Border Walls: Security and the War on Terror in the United States, India, and Israel.

Jones was joined by a panel including Professor Heaven Crawley who leads research on migration and human security at the Centre for Trust, Peace and Social Relations at Coventry University, Elinor Raikes, Regional Representative for the International Rescue Committee’s (IRC) response to the European refugee crisis, and Richard Savage, Global Emergency Response Security Manager for Save the Children.

Collectively, the speakers agreed that in order for the lay public as a general media audience to best apprehend the refugee crisis, it is necessary to dilute the counter-narratives that are consistently published across print and online media, instead prioritising meaningful stories directly reported through contact with migrants and refugees.

This is especially the case when considering borders or walls which are used to enact political narratives of ‘violence at borders’ positioned in terms of terrorist or violent threats to deter movement at these fringe lands. Of course, this lexicon of ‘movement’ is self-stultifying and serves again to challenge the rhetoric of existent media narratives around the refugee crisis.

In the context of the supposed ‘moving wall’ of refugees closest to home, that of the European refugee crisis, a personal reminder of the necessity of this challenge comes from a close friend currently working as camp manager at Lighthouse Relief on the Greek Island of Lesbos supporting those that land on its shoreline. Such support varies from hard labour managing clean-up operations to helping source legal guidance on their rights around seeking asylum, particularly in instances where these are unclear.

The frenzied tension of her email messages relayed from this literal frontline highlight her desire for ‘the top to be blown off’ the conditions of the detention camp on Lesbos where newly landed refugees must report and be effectively walled-in until their release at a point when a return, a stasis or forward drive has been decided for them.

Of the many reporters and journalists that have also arrived on Lesbos’ shores via very different means, with decreasing frequency, little of the actual narratives make it into print. As such, discussions such as those at the Frontline Club offer an essential arena in which to augment the alternative reality of the crisis, unbounded by the walls of mainstream media.

During the panel discussion, Jones drew on statistics from his book, highlighting the temporal shift in number of borders since 1944. At the end of World War II, there were less than 5 border walls around the world; today there are about 780. With such a proliferation comes a whole wave of new and growing security practice at such sites.

Jones’ writing suggests that there must be an active awareness of this proliferation amongst key stakeholders and media. Further, that they – and we – must respond to it. There must be a more transparent drawing of the relation between the hardening of borders and increased deaths at these sites and national acknowledgement that the model and practice of wall building as ‘deterrants’ does not, in reality, mean that fewer migrants are coming to these borderlands but instead that more are dying.

From my own reading and understanding, there is a need to tell individual stories. For many who encounter and counter borders, the prospect of crossing them is far less grave than staying where they are. Of course, this differs based on whether those persons are migrants or refugees but this only goes to reflect that border people are not a homogenous body but have different motivations, hopes and narratives to tell. There must be an urgency to this telling as the militarisation of border controls and funnelling of people on the move to more dangerous crossing points is leading to increased brutality and oppression of these live narratives.

Raikes, who has worked in Greece and across programming in Germany focused on the chaos of social disruption and displacement across the Aegean and Mediterranean seas, describing the ripple effect caused by border closures. Crawley broadened this discussion, identifying the very different demographics of those moving via the Central Mediterranean (Syria to Italy) and Eastern routes (Turkey) and reiterated the need for higher profiling of refugee narratives to better understand the backstories of how persons come to ‘be’ at these places (both geographically and in terms of social situation and context).

Undeniably, there’s a complexity about ‘who’s on the move’ with associated considerations of ‘how’, ‘where to’ and, fundamentally: ‘why?’. These interrogations aren’t asked solely out of a desire to report on circumstance, but so too to function a more viable and effective interface  between reality and policy. Current policy responses are dysfunctional and show gross disparity between what we know about the reasons for peoples’ movements and the response.

And this debate is at once everything about refugees and nothing about refugees. The ‘crisis’ becomes a lens through which country politicians communicate with their citizens via a Trump-esque populist nationalism. This perception becomes a reality, seeping down into local level understanding of the crisis and impacting refugee ‘acceptance’, which is inevitably clouded by fear of the stories that aren’t being shared by their nation’s government and media.

But just as much as these discussions aren’t just about refugees, so too they aren’t singularly about politics. Economics plays in the narration and actualisation of borders in a national show of strength in provision of the weightiest surveillance, detention centres and mass responses such as the Frontex border control that describes its activity with an uncomfortable rhetoric of nation as person: ‘carrying out […] vulnerability assessments, including assessing Member States’ capacity and readiness to face threats and challenges at their external borders.’

So, aside from continuing these discussions and recognising that they are not centred on Europe but apply worldwide, not least the Mexico/US border, there must be a stretch for solutions. Albeit hypothetical, ‘open borders’ is an imperfect but hopeful option. Opponents of ‘open borders’ often don’t recognise that movement of peoples is often temporary and assume that ‘open’ means undocumented and unmoderated.

In fact, very few people want to ‘move’ in this sense. Globally, only 3% of the world’s citizens reside outside of the country in which they were born, including those who have actively elected to do so. Furthermore, global circulatory movement across groups is actually pretty high, with many persons who move countries for a job or a lifestyle change, for instance, ultimately returning to their root nation with forcibly displaced persons often returning to their home nation once a state of peace is to be viewed with hopeful permanence.

We need to look at responses much further ahead while continuing to steadily challenge the desensitisation to the crisis of policy makers, UN member state stakeholders and also of the persons making the tracks who are increasingly taking greater risks that suggest a desensitisation to the barriers and dangers that lie in their way.

The changes wrought by the impact of climate change, the militarisation of civilian populations and mainstream media’s adoption of the ‘middle road to nowhere’ will only cause even more movement. With this, comes more narratives to be exposed, told, heard and addressed.


Image Credit: Kevin Dooley, Flickr

The frenetic mind: No’s Knife

It’s not often that one goes fresh and fragile into a  situation or encounter to be greeted with a bewildering recognition amidst the distracting newness of the thing. This was my experience of Lisa Dwan’s performance of ‘No’s Knife’ at the Old Vic Theatre.

‘No’s Knife’ is a selection of Samuel Beckett’s ‘Texts for Nothing’ (1950-52), 13 short prose pieces written shortly after his novel ‘Malone Dies’. I was familiar with this longer length text, characterising Beckett’s acknowledgement of, and working through, the inevitability of death. From the outset, ‘Malone Dies’ sets itself up to be a certainty , (‘the’ / ‘a’ death), but through the course of the text, readers are invited to assess the information they are given to work out why Malone is so assured in his convictions. The only certainties become the questions themselves.


The same is asked of us in ‘Texts for Nothing’. The title invites interrogation, with the ambigious preposition ‘for’ offering possible interpretations of purpose, value or motivation – are these pieces gratis, or are they purposeless; indeed, who might ‘Nothing’ be if not understood as ‘no-thing’? Quite simply, Beckett manages to disrupt certainty, and give possible importance to the seemingly inconsequential or themes that self-parade as such.

Beckett, and performances of his texts, are often lambasted for being inaccessible to all but the intellectually elite, or pretentious, depending on who’s making the accusations, but my readings and experiences of Beckett have never aligned with either standpoint. I’d never seen any Beckett performed live before, but I found reading his textual work forms strangely thrilling in the jumble of words and mentally worded sounds.

‘No’s Knife’ affected me in a way I hadn’t expected. I’d preliminarily prepared myself to be inspired by Dwan’s reportedly extraordinary performing tour-de-force, projecting accent, emotion and movement into what was effectively a 70-minute monologue, but otherwise to be left empty – ‘sans plus’.


All this happened – and more. It was impossible to experience Beckett or this performance passively. Humans automatically tune into words and make associations or connections, trying to draw threads and to make sense of nonsense. So the piece became both exhausting and rousing, taking on a life of its own to leave me somehow altered, but not necessarily changed. It has been claimed that Beckett’s texts leave one with nothing, but for me it felt like everything and nothing, not quite an emptiness but an unexpected introspection on what it is ‘to be’.

Perhaps this was, in part, because of the very evident contextual relevance of some of the allusions and concerns of the pieces. As Dwan commented during an interview with her co-director, “Beckett wrote these at a time when Europe was trying to understand itself after the war with resonances with the way we, and Europe are – or is currently – understanding itself”.


It may also have had something to do with the following. I have periods where I momentarily lose sense or experience of self; not in a rational questioning of life purpose but as a sometimes alarming, other times otherworldly, disconnect from a sense of being. It happens at the strangest moments, most recently while I was at the hairdresser. A rare event, and one I don’t find particularly enjoyable, I realised I had lapsed into this form of depersonalisation, looking back at a face that wasn’t even remarkable as a stranger’s let alone definable as my own. I’ve never been able to articulate it, but it doesn’t feel surreal, rather alien. For those few seconds until I consciously trigger a transition to ‘sense’, it is as though my existence is in a  vacuum.

It so happened that I had been experiencing a few weeks of this, after not having done so for several years, with episodes becoming increasingly frequent and extended at the time of this performance. There was resonance in the frenetic, often obscure thinking, the disconnect  between self and substance, between thinking and visceral – not that these are dichotomies, but questions raised, albeit actively, and consciously, in a way that demands your consideration as viewer and being.

And it would seem that I am not alone. Dwan comments of her first interaction with the texts: “what I saw was a transcript of how my mind works […]. They’re a real exploration into the self: into who we are – into identity”. In ‘No’s Knife’, Beckett puts the mind on stage, a stage which featured three sets or planes:  one as though looking down into a jagged, swollen, wound in the ground with Dwan strung across it in various Messiah-like contortions; one on the flat studded with rubble and pooling water and a final spotlight on, alternatingly, Dwan’s face and chest or full body sitting in a swinging chair.


The wounds of the stage landscape extend into the fleshy and mental disruptions of the audience, inviting us to examine them in the space of the performance within the prodding fingers of our own mental dialogue. In the first and final texts, Dwan was somehow constrained, either by the crevace of the swing, concentrating all activity into her core while the ambiguity over who, where and ‘if’ she was alive embodied Beckett’s notion that death is a state of being immobile.

The performance we went to was captioned. Aside from offering a ‘meta’ level, the visualised text was a surprisingly powerful addition, albeit one made for other purposes. While the reading or spectating process is not passive – it feels as though something is being done to you – the process of creating narrative is about anticipating the directions the plot might go from the information you are given. There is delight in this enterprise, and one that Beckett repeatedly turns to, only for him to take us in a certain direction that will be completely overturned later on.


We are in the habit of trying to answer these gaps because as social animals we step into the spaces occupied by other human beings to see how we would experience them ourselves. Gutteral, frenetic, comic, self-conscious, desperate, terrible, religious, safe, unstable, isolating, alienating, togetherness, illusion: all were a part of the performance, both explicit and implicit. I have no doubt that the piece will last with me, not only for the resonances I can pin-point, but also for the multiplicity in its brevity – its state of being whole but with missing parts; parts which will not let you rest.


Photo credits: Manuel Harlan

Let’s All be Free

Regular readers of these pages will know that while global health is prioritised as a general theme, the way it is explored ranges from artistic manifestations to coverage of specific clinical conditions and their context-dependent impact. As the ‘Writing Health‘ section demonstrates, I try to unpack what might be understood by health, globally, recognising its many facets, including mental and physical.

Of course, such understandings are limited by the extent to which anyone can really empathise with the reality of another’s daily life however proximal they might be geographically, but I am regularly presented with windows of opportunity that offer, at the very least, a viewing platform into these spaces. One recent example was an invitation to join the East London based ‘Let’s All be Free Film Festival‘ which explores and celebrates what ‘being free’ means to people all over the world, through artistic expression across 5 days, 37 films, 5 venues.

The medium of film is offered up as an opportunity for artists and viewers to enter a forum to  discuss what being  free means to them, and how peace, prosperity and understanding can be promoted through dialogue and discussion. I joined the festival at the Rich Mix cinema in Shoreditch for a weekend screening of their official selection of shorts aiming to help others see the challenges of life, including the struggles people go through in their daily lives.14694646_10154620701709730_1276603551_n

The line-up included short (maximum half an hour) fiction, documentary and expression films from directors in Palestine to the USA (for instance, ‘Ironhead‘, a documentary directed by Thomas C. Johnson & Neal Abbott) back to the UK. This jostling of origins, subject matter and types was surprisingly productive, inviting audience engagement across self-consciously brief time frames, inspiring emotion to jolt us from horror to sorrow to triggered laughter. Ten-minutes of ‘Till Death Do Us Part‘, a documentary directed by Penelope Antorkas, introduced us to the idea of freedom in abandonment from reality with an escape into a young man, Grant’s, obsession with horror films which he watches with compulsion and ritual but in a manner that brings him an overwhelming sense of fulfilment and pleasure. This freedom is, in his words, about being ‘terrified but safe’ in being able to inhabit the storylines and rote-learned scripts of Friday the 13th films.

Inherently meta, this sense of personal liberty echoed across ‘In A Flash‘, a non-verbal expression piece directed by Sophie Austin in which we follow a girl shopping in a Moroccan souk with her mother. Tired of waiting, we track the girl’s sighting of a cat and her pursuit of it until the scent goes cold and the piece ends abruptly. Like Alice down the rabbit hole, and Grant of ‘Till Death do us Part’, she discovers a strange and curious world that is somehow liberating, just as our own viewing of the screenings allow us to experience these expressions, albeit second-hand.

Meanwhile, ‘Piece Of Cake‘, directed by Ella Lentini, and ‘Wally’ (25 mins), an Andy Galloway documentary, explored freedom and wellbeing in a more recognisable interpretation marking the coming out of, in the first instance, a young woman to her parents about her same sex relationship, and in ‘Wally’ of a father, Christian and teacher in Jefferson City, Missouri, of being gay to his entire community. ‘Piece of Cake’ explored the run-up to this act of liberation from fears of parental rejection, disillusion or ‘pretension’, punning on the title, with the line ‘BTW, I’m gay’ iced onto a cake baked for her parents on their anniversary visit to her apartment life in New York.

‘Wally’ pieced together interviews with the protagonist’s three daughters, politicising the focus by commenting on the contemporary community and theological implications of verbalising freedom through an open expression of sexuality, and the tension between liberty and legality, social isolation and personal incarceration. The piece pitches from Wally now and then, covering ‘sickness’ and depression that he describes as being on ‘the inside’ and the transition to the heartsickness he experienced following his disclosure, including the supposed separation from his daughters.


Perhaps most recognisably, the longest length short in this screening, ‘The Black Friday‘ directed by Jozef Nateel, is a documentary covering the day of that name in the summer of 2014. During that period, Israel had launched a large-scale military offensive against the Gaza Strip that lasted for 51 days, with one day cited by Amnesty International and other Human Rights organisations as Black Friday exposing evidence of Israeli war-crimes committed in Rafah during this period with the deaths of over 140  Palestinians in the space of 24 hours.

The short struck a balance between interviews with locals who survived this offensive and superimposed text detailing statistics and events of the day. Above all, it literally fleshed out what it might mean to lose 140 people from your immediate community, and the awareness that history would, inevitably repeat itself. The loss of freedom is as much the substance of this film as verbal  impressions of what it might mean to live freely. The piece features conversations to camera with Hidaya Shamoon, a journalist and filmmaker based in Rafah. In a particularly moving response, she recalls how a woman questioned her motives in filming the attack on Black Friday, to which Shamoonn responded ‘this will not happen in silence’.

Perhaps this is reflective of the joy and success of this festival: it delivers on its promise to record expressions of freedom, and scales it in terms of experience, singular or plural, global location, all drawing on the inextricable impacts on the health of social interactions with those we share our most intimate lives.

For more information, follow Let’s All be Free on Twitter, or head to their website.


Image Credits: A. Bow-Bertrand

Kala Azar: The Overlooked Killer

The title of this article was awarded an Honourable Mention via Global Health NOW’s ‘Untold Stories in Global Health’ competition. It is also available on their blog, here.

It is unsurprising that neglected tropical diseases get the fewest column inches and remain unknown to vast swathes of the general population. But if you were asked what the largest parasitic killer was, after malaria, would you correctly answer Kala-Azar?

Also going by the names of Leishmaniasis and black fever, this isn’t a disease of the European or Northern Hemisphere masses, despite long causing significant fatality figures and appearing on many NGOs agendas—including Médecins Sans Frontières (MSF), which reports treating more than 100,000 people with the disease since 1988.

Endemic in almost 50 countries and with an estimated 200 million at risk, there are an estimated 201,500 – 378,500 cases a year, according to Lepra (an active NGO working in this field). The unseen Leishmania parasite is transmitted by the bite of the equally insidious yet unprepossessing female phlebotomine sandflies. Tropical areas, especially during the autumn harvesting season, prove particularly hospitable to this vector.

Kala-Azar progresses from skin ulcers at the site of infection to the more aggressive form of visceral Leishmaniasis, effectively destroying the immune system. Left untreated, it almost always causes death through complications of any combination of anaemia, weight loss and vital organ failure, notably swelling of the liver and spleen.

It is also associated with poverty: Lepra identifies it as “the poor man’s disease.” For example, sandflies frequently occupy cracks of houses made from mud commonly inhabited by the poor. The disabling aspect of the disease prevents sufferers from being economically self-sufficient while the burden of treatment costs can push their families further towards extreme poverty.

Unfortunately, being identified with and treated for Kala-Azar is fraught with its own dangers. The most effective diagnostic tools are invasive, requiring extraction of either bone marrow or splenic aspirate to visualize amastigotes (an intracellular form without visible external cilia or flagella typifying the leishmanial stage). Invariably, this diagnostic gold standard is unavailable in endemic areas, but serological testing is a common and generally reliable alternative, according to the WHO.

What is life actually like for someone with Kala-Azar? Lepra’s work in Bihar, India offers a telling insight. Consider 8-year old Ruby Kamari, who was originally misdiagnosed with malaria. Only after a series of referrals and 2 rounds of treatment—which proved financially devastating for her family—is she able to eat a little more than half a chapati (flatbread) a day, sleep in more regular cycles and see the melon-sized ballooning of her abdomen lessen.

Another case echoes this debilitating lack of knowledge across the general population: Devi, the father of a 7-year old son who is 2 months into treatment for Kala-Azar remarked, “We thought it was just a simple fever. We live in a hut, we don’t have the knowledge. If a mobile testing facility and treatment facility came to us, it would make life easier.”

Speaking at the London-based Medsin (UCL) conference in 2015, MSF clinician Ana Garcia Mingo shared her experiences working within conflict areas to curb the spread of Kala Azar. She underscored that after any crisis, preventative care is the first thing that stops, but this is also a truism of this disease across the regions it targets.

While there are no prophylactic drugs nor vaccine for the disease, preventative recommendations as per other insect-borne diseases extend to limiting time spent outdoors, particularly from dusk until dawn when sandflies are most active, and application of insect repellent. Indoors, at-risk populations are advised to apply pyrethroid-containing insecticide to furnishings and to make use of bednets.

Although entirely treatable, inexpensive yet effective chemotherapy is lacking in many endemic areas, not least Sudan, according to a 2008 study published in Transactions of the Royal Society of Tropical Medicine & Hygiene. Although the overwhelming portion of those who receive treatment reportedly recover and are highly unlikely to contract the disease again, access to treatment and both donor and health system awareness of the disease is varied but still, devastatingly, the disease occupies a discourse of the ‘neglected.’


Image Credit: Ruby and her family look out from beneath their bednet. Peter Canton via Lepra.

Relief/Development: bridging the divide

When one reads a news article titled ‘policy change crucial for international development’ or ‘governments must get behind the relief effort in XYZ nation, in XYZ context’, one rarely pauses to consider the link, interchangeability or otherwise of ‘relief’ and ‘development’ as terms and actualities. Perhaps it is the history as an English Literature student, but ingrained in me is the habit of dissecting every term to the sum of its parts and to consider how it interacts variously given its context, narratorial voice, intended audience and so on. But this scrutiny over terminology is necessary from any critical reader, particularly one concerned with global health, and the international agenda for it determines accountability, motivation and outcome.

So, what’s in a name? The two definitions most readily associated with ‘relief’ include a feeling or encouragement of emotions of reassurance following periods of anxiety or high stress as well as financial or practically oriented assistance given to those parties or persons in critical need or difficulty. Meanwhile, ‘development’ is most generally associated with a specifiable state of growth, optimistically linked with progress or change through space, time and people. The crossovers between the two are apparent and, indeed, rather than considering each term and concept in silo, it is best to see them as a continuum. In temporal terms, relief humanitarian assistance usually segues into development, but this chronology is not always linear with the two happening in tandem in many circumstances of humanitarian crisis,  fragile states and insecure environments.

But this broad brush approach to theory does not always trickle down into good practice, which returns us to the reason behind discussing these terms and states in the first place. Humanitarian, relief and international development organisations usually pitch themselves as just that – umbrella groups that want to address the acute and the chronic like the most forward-thinking, prophylactic minded doctor. However, the two states have diverse objectives and priorities as usually a different government department is involved in allocating relief aid funding to that involved with international development. This is evidenced in the United Kingdom’s Department for International Development (DFID) which regularly has to clarify the position of it’s central funding mechanism, UKAid Direct, which awards grants to small and medium sized UK and International Civil Society Organisations to reduce poverty overseas.  It was formerly known as the Global Poverty Action Fund (GPAF) but this titular revision also likely has something to do with managing interpretation and associated expectations.

The divide is also widened in related funded  gaps frequently carved through donor motivations and constraints that are, at times, sadly at cross purposes to those in most need. The group of diseases that fall under ‘Neglected Tropical Diseases‘, such as Kala Azar and leprosy are, in part, so categorised because they are less de mode, or emotive than some of the often great, white man killers such as AIDs which dominated funding and coverage in the late twentieth-century across the United States. So too, the missions around ‘relief’ and ‘development’ demand and employ different skills with income generation a priority of current development such as the food security approach. Furthermore, different priority is given to sustainability. Vaccination programmes, a cornerstone of many development initiatives, are frequently hard to implement in anything but a scatterfire manner in acute crisis zones such as mutating refugee camps through which peoples often pass unidentified.

To bridge these gaps, it seems that best practice is to both speak about and act on development in relief and relief in development. There is a clear opportunity here for researchers and workers in disaster preparedness (i.e. the measures taken to prepare for and reduce the effects of disasters) to increasingly bring these two closer together, so that when relief is needed, it is readily available and part of a comprehensive, on-going development effort.


Image Credit: Jonction, Geneva. A.Bow-Bertrand

Brexit and Non-place

What’s the current situation?

It is a week since almost half (48% to 52%) of the United Kingdom (UK) reeled at the news that the majority had voted to leave the European Union (EU) – its constitution, ideals and politico-economic partnership. Since then the respective leave and remain campaigns have been posthumously dissected, their leaders and leadership questioned and the integrity and informedness of the voting public duly challenged.

As the title of this blog suggests, MattersduMonde is about matters that affect the world, often starting from the local, and health-based infrastructure with previous posts exploring the National Health Service and foreign aid programmes via the Department for International Development (DFID). However, if nothing else, these critical days since the largest suffrage determined political decision taken during my voting history, I have been struck by countrywide engagement with what it means to be the United Kingdom, more commonly – and loosely – used interchangeably with notions of ‘Britain’ and ‘British’.

Notwithstanding the disappointing level of abstaining voters particularly of the 18-24 age range, and the widely varying degrees of information or mis-information (given the complex, often contradictory and repeatedly deceitful policies of both campaigns) held by each voting citizen, every one of those 30 million plus voters has an opinion, before, during and most importantly following the outcome of last week’s referendum.

Bit of a mess?

Bit of a mess? Somerset House ‘Utopia’ exhibition, detailed below.


Where does this ‘leave’ us?

While there is real value in reading, sharing and re-writing the present experiences and reactions of the UK’s constituents, it is imperative to note that while a local issue for many, the implications of this vote have global consequences, from Donald Trump’s looming presence in Scotland last Friday morning and that state’s predicted distancing from the result, to Northern Ireland’s renewed clamour for independence. Fundamentally, the economic, social and literal health of the populace of the UK we are ever a part of is ironically dependent on the peoples and places beyond this island’s increasingly literal borders.

Many leave voters cast their weight behind a campaign that promised an impossible finite end to free movement to the UK associated with membership of the EU. Many of these same voters claim it is acceptable for immigration in the form of skilled workers – doctors, lawyers, pharmacists. All of which crystallises into a persistent and little explored anxiety that this referendum was seen less as a heterogeneous, multi-faceted decision of unity in all its forms, and more of a reverse process founded on the widely silent, but influential idea of what the UK or ‘Britain’ really is.

The much-cited statistics that show a demographic skewing of the older population across England, Northern Ireland, Scotland and Wales towards a leave vote and vice versa at the other end of the age scale should be increasingly seen not based on electoral or life experience, but in terms of how this shaped one’s understanding of what it is to be British. What is palpably clear as orchestrator of the leave campaign, Boris Johnson, has shown in his sudden shadowy disappearance from the now 5-way race Conservative leadership line-up, is that the people of Britain and their understandings of it are so wildly different, that to try and unify them for a future Britain that is based on modern change, innovation and progression, is an insurmountable ask.

Utopian vacancies at Somerset House exhibition, 2016.

Utopian vacancies at Somerset House exhibition, 2016.

Indeed, our respective understandings of Britain and our role as citizens of this nation are most formally pinned to the ‘Life in the UK’ citizenship test first introduced in 2013 under the imperative ‘prove your knowledge of English or citizenship and settling’. Such lexicon of proof and knowledge are constructs bandied about during this referendum as though quantifiable. But of course, it goes without saying that such a test is so anachronistic when so many current citizens would not pass. It is intellectually comic that one of the questions in the aforementioned test is as follows:

Screen Shot 2016-06-30 at 15.28.28

Reproduced from the condensed version of the YouGov citizenship test for the Independent.

Aside from ideological correctness of such answers, many of the other constituent questions are so divorced from educational-derived curricular knowledge as well as national identity that this test’s value – and marker for ‘Britishness’ – is undermined.


Where has this come from?

Rather than suggest what our future will look like, as I don’t think that there is a clear nor comprehensive vision, or reality, this discussion turns instead to look back through history and literature to the model of utopian thinking and impossible dreaming that has coloured and discoloured every sovereign state and every independence narrative. Utopian thinking, the American dream, scriptural, Edenic Paradise are all permutations of a similar model characteristic of humanity – the striving for something that is perfect in the eyes of the perceiver.

Of course, perception rarely correlates with feasibility which in turn causes the very personal and emotive fall-out experienced by so many of us in the UK and beyond this past week. Furthermore, ‘utopia’ is etymologically rich, deriving from Greek stems to form the hybrid of ‘non-place’. From Thomas More’s possibility dreams (Utopia 1516) to Francis Bacon’s political ideology (New Atlantis 1627) and Margaret Cavendish’s wonderland of the imagination, the seventeenth century reader and audience alike were accustomed to the idea of ‘a world elsewhere’. In itself an epoch of upheaval across currencies of religion, philosophy and politics, these learnings and writings are increasingly critical to the immediate now.

In addition to the main Somerset House exhibition and series of talks, there are collaborative pieces running in conjunction with the neighbouring Courtauld Institute and King's College London

In addition to the main Somerset House exhibition and series of talks, there are collaborative pieces running in conjunction with the neighbouring Courtauld Institute and King’s College London.

The debt Thomas More owes to humanism for the origins of Utopia is an area in which much debate has been devoted, in part due to the malleable connotations and contextual meaning of pigeonholed definitions. The Renaissance saw a resurrection of the classics and humanists heralded furthering the arts of reason and the dignity of man within the Christian doctrinal frameworks. Famously described as a ‘revival of good letters’, humanism was perhaps less ideological than often attested.

Whilst the humanist influences of Plato and Erasmus are powerfully vocal in Utopia, so too is a contradictory turn from them, most notably in discussions which theorise beyond the boundaries of Christian monogamy both on personal and national levels. The principal elements of utopian writing so understood, are a chance landing or shipwreck on the coast of what turns out to be an ideal commonwealth followed by a return to – specifically – Europe, and a commentary on what has been remarked.


What are the dangers of utopian thinking?

So too, as argued by Margaret Cavendish (1623-73) who engaged with and practised a form of experimental science through her literature, imaginative freedom is considered a prerequisite for intellectual maturity, social change and intellectual development. Indeed, commonly held truths (or unexamined perceptions or ‘proof’ of what Britain is) are utopian experiences that must be deconstructed for they are ultimately unavailable for representation and appropriation.

In Cavendish’s The Description of the New World, Called the Blazing-World (1666), Cavendish, herself the actual and literary figure of the ‘Duchess’ of Newcastle finds herself on a satirical trajectory as scribe to a beautiful maiden – the Empress – who writes her way into another world with different stars in the sky and creatures on its shorelines. When the Empress desires to share this found world, the guiding-force of the Duchess encourages her to construct her own, redirecting utopian expectation away from material production to shared creative activity.

The ‘Britain’ idealized in the subconscious of all voters is a utopia of sorts – not a venture until is examined in the open – but still an irreconcilable state. The other; the ‘European’ in this case, like the Orient and prolific discourses in the field of global health of the ‘west and the rest’ quickly become the subject of the languages of dream and Utopia, ‘the object of a powerful fantasy’ (Hall, 1992).

 Readers and citizens must surely be left wondering about the value of the ‘otherness’ of Utopia and its paradoxical comparability with sixteenth-century England. Unlike Plato’s Republic, Utopia is not a maquette for an ideal commonwealth; it seems more dramatically to be one of More’s theatrical metaphors ‘in which disparate and seemingly discontinuous aspects of […] existence come together, touch, and resonate’ (Greenblatt, p. 27).



And the possibilities of such dreaming?

The contradictory design and rhetorical paradoxes of these cited utopian writings are self-interrogative, challenging, and reflects the wealth and the weakness of words to influence worlds. The final line of More’s Utopia hovers in the subjunctive, so what happens next is for us to decide. Certainly, the utopia of one human may be the dystopia of another, so to the very last, the polemical nature of the literature and author remain. More specifically, when angling this pitch through a perspective of health and globality, the idea of a global society should not be construed as a utopian world free of conflict. Rather, as in most national societies, one would expect a global society to be characterised by ongoing political conflict and competing views. As Frenk (2010) notes, ‘what the notion of a global society does imply is that underpinning such conflicts would be a widely shared understanding of health interdependence and an acceptance of some responsibility for the health of others as members of the same society—in other words, a shared commitment to realisation of health as a human right based on a recognition of our common humanity’.

Is this pathetic fallacy? Dark and gloomy Somerset House quad the weekend post-Brexit vote

Is this pathetic fallacy? Dark and gloomy Somerset House quad the weekend post-Brexit vote. Might just be the monochrome filter.

It so happens that it is the 500th anniversary of More’s Utopia celebrated in a challenging and ever-relevant events programme at London’s Somerset House. Yet, as the programme preface articulates: the text and commemorative events are, once again, ‘not a blueprint for the future, instead he [More] places importance on the process of dreaming in the now. His work continues to inspire communities and provide a framework for true innovation in our time.’ In a world that has just witnessed the return of ESA astrologer Tim Peake from the International Space Station, surely the brand of extra-terrestrial exploration and utopian dreaming as read through Francis Goodwin’s The Man in the Moone (1638) indicates the worth in looking at the bigger picture and reassessing the simple but time-old answers we would give to an alien asking ‘what is Britain’?

With constant personal reflection translated into political representativeness, I think there might be hope for a Britain that is united in understanding the nation is ‘great’ for being in flux, flawed but imperatively free. A renewed brand of utopian ideology, distanced from it as a reality, will be instrumental in shaping this future.

As simple as an OS map.

‘Paths to Utopia’: as simple as an OS map…



Bruce, S. (ed.), (1999) Three Early Modern Utopias: Utopia, New Atlantis and the Isle of Pines (Oxford: Oxford University Press)

Comp, A. and F. K. Pizor (eds.) (1971), The Man in the Moone: An Anthology of Antique Science Fiction and Fantasy, (London: Sidgwick and Jackson)Frank E. and Fritzie P. Manuel (1979), Utopian Thought in the Western World (New York: Belknap Press).

Frenk, J. et al (2010), Global Health is Public Health in The Lancet. Vol. 375; pp. 535-6.

Greenblatt, S. (1980), Renaissance Self-Fashioning: From More to Shakespeare (London: The University of Chicago Press)

Hall, S. (1992), The West and the Rest: Discourse and Power. Available from: <; [Accessed 28 June 2016]

Lilley, K. (ed.) (1994), The Blazing World and Other Writings, ed. Kate Lilley (Harmondsworth: Penguin)

Logan, G. M. (1983), The Meaning of More’s Utopia (New Jersey: Princeton University Press)

Nelson, E., Greek Nonsense in More’s Utopia. The Historical Journal, 44 (2001), pp. 889-917.

Skinner, Q. (2002), Visions of Politics. Volume III: Hobbes and Civil Science (Cambridge: Cambridge University Press)

Image Credits (all): A. Bow-Bertrand. The featured image reads ‘Utopia’ transliterated into Thomas More’s alphabet.

Policy in Practice: Cambridge

Abstract: 2016 is a critical year for sustainable development warranting this urban health proposal for Cambridge. With exponential population growth forecasts and some of the highest levels of homelessness, air pollution and house price rises across UK cities, interventions must be multi-sectoral. Evidence-based recommendations are to: 1) develop affordable housing prioritising settlement for the destitute identity group, and 2) reduce air pollution through improved safety and attractiveness of pedestrian areas. Review and target periods of 12- and 36-months will support and shape this vision for a modern, healthy city by 2030.


It was a dreary morning when the wheels / Rolled over a wide plain o’erhung with clouds, / And nothing cheered our way till first we saw / The long-roofed chapel of King’s College [Cambridge, William Wordsworth]

Wordsworth’s verbal mapping and visual transit into Cambridge is not so unlike our own. To know Cambridge is to come to it afresh, travelling into the urban nexus with the potential to offer recommendations that benefit from perspective: both academic and geographic. The city’s low lying above sea level and development height restrictions means that, as for Wordsworth, it remains visible to the unaided human eye across the surrounding lowlands. Unlike Wordsworth’s 18th-century movement across ‘wide plain’ into an urban nexus marked by King’s College Chapel, current comers register the place as a city – one which was conferred this status in 1951 in recognition of its history and continued behaviours as a productive space. Whether via East Anglian rail tracks on a 46-minute train journey from London’s King’s Cross station, or along the M11 or A14 roads, or rising through the system of locks and weirs as a bargerman, the city evidences the challenge of any modern urban hub: how to support the health of its users while ensuring sustainability for future peoples. By considering interactions within the urban system, forward-looking policy can be employed to change and benefit the health of Cambridge, noteworthy for its status as a magnet to people variously acting as ‘commuters’ of business, trade, travel and intellect. Cambridge’s citizens are a product of their city – and vice versa.

Through this overview of existent urban health policies and projects, the Cambridge polis has demonstrated its willingness to consider and customize initiatives from across the world to most effectively meet local needs. This wide-reaching outlook relates the local to global health, along a people-community-planet pathway (as employed by the Cambridge Sustainable Food Charter, 2014). This report offers renewed vision for Cambridge between 2016-2030 and negotiates recommendations in terms of amenability, costing, risk and feasibility. Cambridge has been lauded a pioneering city in terms of academia and more recently business, with the adoption of the ‘Silicon Fen’ appellation (referring to the regional aggregation of biotechnology based businesses) and one which is developing. In the Centre for Cities (2016) list, Cambridge was ranked sixth of the ten fastest-growing cities by population in the UK with an annual growth rate of 1.4%. Within this demographic swell, the Cambridge City Council’s Improving Health Plan (2008 p5) reported that ‘the number of people aged 65+ in Cambridgeshire is expected to rise by 60%’ by 2021. As a result of this context, this report focuses on the urban challenges of sustainable settlement and air pollution, recommended for their immediate relevance and demonstrable capacity to influence urban-related health outcomes for the major share of this population.

To date, sustainable settlement and affordable housing initiatives have frequently been included in urban health reports pertaining to the Cambridge city region in recognition of its considerable tourist capital and population growth. There is, however, room to improve. Such reviews have considered this demographic swell conceptually as a case of more people equating to a need for more houses, rather than recognizing the mobility and heterogeneity of population sub-groups. Indeed, Yvonne Rydin (2012 p1) highlights that average levels of health witnessed in Cambridge: ‘hide the effect of socioeconomic inequality within urban areas’. Urban poverty exists and persists in Cambridge. Last year, the main regional news outlet Cambridge News (2015) reported a 41% increase in homelessness associated with a range of factors: job losses, welfare reform and benefit sanctions. At present, there are some group-specific support services such as the University-based Streetbite society and Jimmy’s homeless shelter working on a short-term care model. For many of these individuals, their homelessness is a symptom of being out-priced from a depleting stock of affordable housing. Indeed, according to the Centre for Cities (2016) report, Cambridge came out top in terms of the highest rises in house price with a staggering 12.5% annual growth across 2014-2015 [Figure 1]. So too, it was ranked alongside Oxford and London as the least affordable cities in relation to the British average. Existent plans to increase the housing stock and to push through welfare reforms while demonstrative of sound regulatory structures and nurturing governance, overlook the need for new housing stock to be targeted to specific audiences within the overall population swell.

Screen Shot 2016-06-15 at 21.06.23A similarly broad stroke, if simplistic, approach is witnessed in existent management and reduction of air pollution measures in the city. Mark Slade (ITV NEWS, 2016) remarked that: ‘air pollution is a problem for people’s health, we know that it is a problem for the environment’. Meanwhile, local think-tank Cambridge Past, Present & Future (2016) report that carbon dioxide emissions in Cambridge regularly breech UK and EU legal limits, contributing considerably to elevated air pollution and ‘must be tackled as a chronic public health issue’ directly associated with morbidity. Once again, this report advocates starting with the urban citizen and their unique, decentralized patterns of movement within – and use of – the city centre. I would invite you to imagine that you are rushing along King’s Parade to attend a choral service at King’s College Chapel on a Sunday morning [Figures 2, 3]. You are faced with a transit conundrum: cycle and plough through pedestrians who step onto the Parade for that all important Instagram snapshot; walk and risk being late for the service, or jump into a Hackney carriage for a horn-blaring drive. Scale-up this scenario to a weekly occurrence and this seemingly flippant narrative becomes one in which all three options have quantifiable urban, physical and psychological health impacts pertaining to air pollution. As an existent conundrum, the City Council has implemented traffic-centric actions such as guided bus routes and removal of Park & Ride charges so promoting public transport use and reconsidering personal vehicle use via the regional CamShare scheme. As a corollary, there has been effective promotion of walking habits. Certainly, the objective to reduce air pollution has the associated effect of protecting the local environment. As has commonly been attested, a healthy city is one which is pedestrian friendly. According to Clayton Lane of the Institute for Transportation and Development Policy, ‘the pedestrian is the indicator species for a sustainable transport system – and, it turns out, for a healthy one’ (DeWeerdt, 2015). Indeed, many thoroughfares in Cambridge’s centre are pedestrianized but what does this mean in practice? Too frequently this equates to narrow or poorly demarcated pedestrian areas such as the sidewalks of King’s Parade [Figures 1,2] that are regularly transgressed by pedestrians. So too, these zones are not always functional in terms of personal aesthetic or evaluations of security. In summary, current measures to reduce air pollution in Cambridge are a piecemeal effort that requires greater nuancing. As Executive Councillor for Planning and Climate Change Tim Ward identifies, ‘although the City Council has undertaken a significant amount of action in the past five years … climate change [and air pollution] still presents very significant risks’ (Cambridge City Council, 2012).

Many existent initiatives in the county and at a global health level reach their published expiry date in 2030, namely the Cambridge 2030 Vision project, and more latterly the Sustainable Development Goals. For ease of monitoring and comparison, this end-date has been chosen to achieve the proposed targets as below delineated to improve the health of persons living in Cambridge. The individual human user and consumer of the urban space must be the main beneficiary for the proposed set of initiatives, reaping complementary benefits, with many of the lower scale actions immediately delivering quantifiable changes and improvements in health. Furthermore, by appropriating the model of Cambridge University’s 2010-2020 Carbon Management Plan, there will be 12- and 36-month targets for policy development and management drafted in the Gantt Chart following:

Screen Shot 2016-06-15 at 21.06.57

This report recommends a 2030 target of affordable housing for all, a reassessment of council and social housing selling practices and prioritisation of settlement for the destitute population. This housing must be socially sustainable factoring in the projected rise in city house prices to ensure that residents are not out-priced, possibly for the second time. This will reduce the numbers of street-dwelling destitute so improving urban sanitation but will also augment the image of the city with attractiveness key to its magnetism for commerce and creativity. This intervention will require the appropriation of disused buildings, promotion of room-to-lets within personal properties for short-term provision and a reconsideration of brownfield sites ‘that might have development potential’ (Cambridge Past, Present & Future, 2014) within the urban green belt. This process will reap energy efficiency co-benefits by adopting the most advanced energy efficient repurposing build methods. Meanwhile, air pollution will be reduced through a comprehensive review and overhaul of pedestrian areas and walkways in the city to promote carbon efficient modes of movement and a transition from vehicle use. Indeed, the archaic limits of the city are marked by the green belt so improvements made in the present must be sustainable on-going in a city uniquely preserved from patterns of urban sprawl due to its compact nature and inherent walkability. The majority of pedestrian areas in the city are also cycle routes. The two can productively co-exist, but there must be clear zoning [Figure 5], introduction of pedestrian lanes in the wards furthest from the market epicenter and improvement of existent pavements. For instance, the walkways straddling Sidgwick Avenue [Figure 4] are inhospitable and represent a trip hazard as tree roots have surfaced. In this particular instance, an add-on benefit of resurfacing would be to consider the attractiveness of both walking routes and their value to users in terms of commodity and safety. Van Cauwenberg et al. (2012) support this imperative to make pedestrian lanes ‘pretty’ and recommend that tree planting becomes central – rather than ancillary – to road planning, possibly encouraging users to walk further. Many routes would benefit from a green lane, implemented through citywide planting of trees and maintenance of the existent stock. In addition to the beneficial carbon offsets of increased canopy coverage in the city and associated disruption of the urban heat island effect (Corburn, 2009), walking promotes health. Indeed, Cambridge City Council’s brochures promoting 1-3 mile walking tours and pedestrianized commuter routes would satisfy the UK government’s weekly physical activity recommendations of walking two 1-mile journeys daily (Walking for Health, 2013). The associated global health benefits of adequate physical activity acts prophylactically warding against non-communicable diseases and improving mental health and combating stress, (Klaperski et al., 2013) in turn reducing the local health system load.

These recommendations function across comprehensive plans projecting towards 2030, but are also characterized by meaningful, microcosmic behaviours and actions. Indeed, Cambridge will always be a city in flux; the nerveline of the River Cam symbolizes transition, arrival and departure; but the landed area will remain largely constant given planning restrictions and limited scope for urban sprawl. By adopting these initiatives that prioritise sustainable and cost-effective repurposing, by 2030, Cambridge will have secured its position as a self-supporting urban centre able to share its models of urban heath, affordable settlements, social progress and carbon efficiency to other cities.

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Asher, L et al. (2012) Most older pedestrians are unable to cross the road in time: a cross-sectional study. Age Ageing 41 (5), pp 690-694.

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Burdett, R., and Taylor, M. (2011) Can Cities Be Good For You?, in Cities Health and Well-being Urban Age Conference Newspaper.

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Cambridge City Council (2016) The Single Homelessness Service. Cambridge. Available from: [Accessed 5 May 2016]

Cambridge City Seminar (2015) Urban Ecologies Conference: ‘From Urban Ecology to Ecological Urbanism: An Ambiguous Trajectory’, 27 October 2015 United Kingdom. Cambridge: University of Cambridge

Cambridge Cyrenians (2011) Accommodation Service: Cambridge City and homeless people. Cambridge. Available from: [Accessed 9 May 2016]

Cambridge Past, Present & Future (2014) Possible Brownfield Sites within the Urban Area of Cambridge [online]. Cambridge. Available from: [Accessed 6 May 2016]

Cambridge Past, Present & Future (2016) Planning and Heritage [online]. Cambridge. Available from: [Accessed 12 May 2016]

Cambridge Streetbite (2015) Cambridge Streetbite Society. Cambridge. Available from: [Accessed 9 May 2016]

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Corburn, J. (2009) Cities, Climate Change and Urban Heat Island Migration: Localising Global Environmental Science. Urban Studies 46 (2), pp 413-427. 

CPPF (2013) 2030 Vision for the Cambridge Sub-region [online]. Cambridge. Available from: [Accessed 10 May 2016]

DeWeerdt, S. (2015) Mobility: The urban downshift. Nature 531 (S52-S53)

Fairhurst, T. (2016) Climate Change: Quantifying the Benefits of Urban Trees in Cambridge. Cambridge. Available from: [Accessed 11 May 2016]

Fleckenstein, L (2006) Greening to Promote Urban Health: Strategies for Environmental Health Promotion Interventions. MSc. University of Pittsburgh

Haines, A. et al (2012) Promoting Health and Advancing Development through Improved Housing in Low-Income Settings. Journal of Urban Health 90 (Bulletin of the New York Academy of Medicine)

Hall, S (2012) City, Street and Citizen: The Measure of the Ordinary. London: Routledge

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Jimmy’s (2016) Jimmy’s Cambridge. Cambridge. Available from: [Accessed 8 May 2016]

Klaperski, S. et al. (203) Does the level of physical exercise affect physiological and psychological responses to psychosocial stress in women? Psychology of Sport and Science 14 (10), pp. 266-274.

Laverty, A et al. (2013) Active travel to work and cardiovascular risk factors in the United Kingdom. American Journal of Preventative Medicine 45 (3), pp 282-288.

McDonald, S (2015) Fantastic Cities. London: Chronicle Books

Mindell, J et al. (2012) Exposure-Based, ‘Like-for-Like’ Assessment of Road Safety by Travel Mode Using Routine Health Data. PLoS One 7 (12).

Mindell, J. and Watkins, S (2010) Transport and Health: A Brief Introduction. Perspectives in Public Health 130 (2), p 57.

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Preston, J., and Rajé, F. (2006) Accessibility, mobility and transport-related social exclusion. Journal of Transport Geography 15 (3), pp 151-160.

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Image Credits:

Footer panorama: The River Cam. KBJX6, 2015.

Header panorama: From King’s College Chapel. A. Bow-Bertrand.

What’s ethical about that?

This is the final blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. You can read the other posts here. My work was facilitated by Lepra, but all views expressed are my own.

Outside Lepra Office, Sirajganj. Image Credit: A. Bow-Bertrand

Outside Lepra Office, Sirajganj. Image Credit: A. Bow-Bertrand

One of the prerequisites of any primary data collection research project is ethical clearance. In the case of work beyond the bounds of the UK, this means both in-country and university specific proposals and checks. It’s a painful, but necessary process, and as the wise-guys on my University College London (UCL) ethics committee crack, the process isn’t over once you’ve received the letter saying ‘go for it’ (it kind of is, but obviously you can’t suddenly morph into an amoral researcher à la Victor Frankenstein, but UCL don’t really do jokes, so I’ll just leave that there).

Flippancy aside, there have been many points during my time in Bangladesh where I have actually been more than usually aware of self-doubt, which is better figured as ‘researcher reflexivity’ for the purposes of a Masters dissertation report. Questions such as ‘what should I do here?’, to ‘how do I eat with my hand without making everyone watching me feel physically sick?’ or ‘what’s right?’ cropped up on more occasions than I might have anticipated, some of which will resonate with others who have carried out fieldwork in non-native countries, and possibly in languages in which they are not conversant.

View of Lepra Office, Sirajganj. Image Credit: A.Bow-Bertrand

View of Lepra Office, Sirajganj. Image Credit: A.Bow-Bertrand

Both non-fluency and non-nativity were true of my status researching in Bangladesh. Certainly, the investigative scope and my suitability were deemed appropriate by the ethics round table, but the everyday reality raised ethical, or rather moral (the two not necessarily being interchangeable, the latter representing a personally bound set of values rather than perhaps an institutional status quo) considerations. I am fully aware that my work here would have been near impossible without the facilitation of Lepra who supported me from sourcing ‘in-field’ accommodation (incidentally a lovely top floor room in their offices), liaising with their remote clinic staff during the recruitment process and acquiring a Bengali-English translator.

In many ways, their support mitigated many logistical and personnel related ethical dilemmas that may otherwise have arisen, including sustainability of interaction and management of medical and psychological circumstances established or exposed through the course of my in-depth interviews and focus group discussions. Indeed, as the staff here remark, the majority of the participants involved in my research had at one stage been treated or had their conditions managed by the Lepra team or associated government staff. Lepra is an entirely non-profit organisation, reflected in their two-pronged methodology in Bangladesh: early detection of leprosy cases alongside health education and the provision of free disability or reaction management and multi-drug-resistant therapy (MDT) for all identified persons with leprosy.

DFID group; participatory observation. Image Credit: A.Bow-Bertrand

DFID group; participatory observation. Image Credit: A.Bow-Bertrand

This free at the point of care delivery is a divergence from the charges imposed on participants for other diseases with many of their medical histories clouded by financial crisis through travelling, without relief or clarity, between local health service doctors unaware that the person before them was presenting with leprosy. For those who found themselves too financially crippled to pursue treatment or, indeed, prior to their awareness or referral to Lepra, there are common narratives of self-medication in the form of daubing non-itchy anaesthetic patches (a telltale early sign of leprosy) with ghee, and of doubled visits to the mosque to pray for deliverance. For the majority, Lepra’s infiltration into their lives represented a proven treatment, the hope of a restoration of their former life, and a manageable programme that was not financially restrictive.

One side-effect of this is that many such participants feel indebted to Lepra on personal levels of trust and gratitude. It was little surprise that all participants invited to my research programme agreed on first invitation – and willingly so. This was the first ethical minefield to navigate – managing participant expectations, and iterating their option to either decline participation at invitation or at any moment during data collection without any prejudicial treatment towards them from Lepra, and vice versa should they decide to take part. This aside, the lesser acknowledged and perhaps unexpected ‘what should I do?’ rhetoric was associated with information provision.

Image Credit: A.Bow-Bertrand

Image Credit: A.Bow-Bertrand

I am all too aware of the pitfalls of the so called white-saviour complex, something that my own privilege denies full dissociation from. However, a lesser extent of the saviour debate manifested in education or what such a narrative would most likely term ‘enlightenment’. While any patient diagnosed with leprosy by the Lepra central hub and clinic stations who is then marked for MDT treatment must compulsorily receive health information relating to the causes of leprosy, its infectivity and complication management such as washing techniques to limit the potential development and recurrence of ulcers, there is evidence that there are failures in comprehension and dissemination. A blanket question asked to all interviewees was ‘what do you think is the cause of leprosy?’ Largely, the literate participants identified germs or bacterium as causative agents.

But at least half of all participants expressed uncertainty, or a host of other perceived factors deriving from places as diverse as religious scripture, cinema, folklore and personal imagination. Amongst the most deviant answers were ‘hot summer air’, ‘sin’, ‘a cut on my finger’. One of the gold standards of research, particularly qualitative which more typically garners – moreover, encourages – personal narratives, is lack of expressed surprise or judgement. I have a dead-pan poker face on tap when required (cultivated from a childhood with a twin who tells even worse jokes than I do), but such responses did not inspire judgement so much as a dilemma – to educate or not? My personal first point of inquiry if I were to suffer from any condition – including, ironically, mental health – would be to try to identify the cause or trigger. How else does one begin to contemplate seeking an appropriate course of treatment or getting one’s head around the nature of our own health without this knowledge?


Children of the focus group discussion participants arrive to wave us off. Image Credit: A. Bow-Bertrand

Of course, I wanted to pause the interview and throw ‘germs’ into the equation, for it has been proven that health condition knowledge not only empowers persons with leprosy to manage and even mitigate prejudiced comments based on such unfounded misinformation, but also feeds into an effective preventative strategy. However, how does someone – me – who is neither a clinician nor a person with leprosy inform said participant of the actual cause without somehow sounding condescending or irreversibly traversing the boundaries between researcher and medical care professional? In actuality, it is very difficult. The first time the situation arose I questioned why I didn’t pause then and there, but something instinctively told me that a passing correction was neither context nor time appropriate.

For many participants, including those who have no idea what has caused their leprosy, this is not due to ignorance, but rather a process of consideration that has not provided any understandings, or an inductive method that has established their own system of meaning, even one that is incorrect according to the biomedical model. On the second instance, I was prepped at the end of the interview with a bog-standard Lepra information leaflet, which I was able to talk the participant through with the support of clinic staff. In many instances the participants were willing to reassess their disease understandings, but for most part the fundamental truths remain the same, and all that really matter – that following the provided course of MDT and self-care programme they can restore their health to at least a functional level while personal treatment adherence limits the chances of both relapse and disability progression.

This research has highlighted that there is a lot to learn – on both sides of the table, or on the same side if you’re a fan of bench seats, which I absolutely am.

Leaning, Jamuna River. Image Credit: A.Bow-Bertrand

Leaning, Jamuna River. Image Credit: A.Bow-Bertrand

Lost in Translation?

This is the third blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. You can read the other posts here. My work was facilitated by Lepra, but all views expressed are my own.

30 words a day. That was the target. While I’m not as well-versed in Bangla as I would have liked in the final days of my stay, I have developed a potentially useless food and drinks vocabulary, as well as being able to throw about basic emotions. No doubt my everyday spatterings are loosely translated as ‘pumpkin, happy, I’ll eat fish tonight, comfortable – are you?, thanks, tasty’. Fortuitously, I have had both a facilitator and translator while working with Lepra. The former – Chanchal, a coordinator of the leprosy programme in Sirajganj was a welcome surprise, but a necessary third party during interviews able to support my official translator – Raha, who also happened to be a first year student of English Literature at Dhaka University and the regional director’s daughter.

Raha and I in the gardens of the former summer residence of poet R. Tagore. Image Credit: A. Bow-Bertrand

Raha and I in the gardens of the former summer residence of poet R. Tagore. Image Credit: A. Bow-Bertrand

Between us we completed thirty-one in-depth interviews. I’d like to add ‘successfully’ because isn’t that the popular lexical precursor to ‘completed’ but such a marker of quality is too subjective to be warranted, and for all our peaceable interactions, the data collection approaches of interviews and focus group discussions were not without their challenges. Above all, these included the two-way struggle to be heard, or rather ‘heard’ in the oscillating rapport between participant and I. Prior to engaging with the team in Bangladesh I had spoken to Cahn Vasudevan, a longtime supporter of the Colchester branch of Lepra and mental health researcher in his own right. It was his guidance that shaped my persistent focus that the people whom were sharing with me their stories and answers were just that – people. Not subjects, certainly, participants perhaps but thinking, feeling beings above all.

This trip to Bangladesh is the first solo travels I have made to a country where I cannot confidently make myself understood in the native tongue. Through no effort of my own Gallic is in my blood thanks to my Montpelier born Dad, while Spanish and some Central American dialects have been what my Curriculum Vitae most probably lists as something horrific i.e. ‘linguistic passions’. Sadly enough this is actually entirely true. I always favoured Spanish studies over say Ancient Greek, purely because of a cost-per-use attitude. I’m an aficionado of all things Hispanic (apologies eye-rollers, I am being a little facetious) and have made my entire family very aware that I wish to relocate to Mexico post-Masters, so if they want to see me again they better start banking those air miles.

Image Credit: A. Bow-Bertrand

Image Credit: A. Bow-Bertrand

Anyway, apart from sounding like an intolerable voluntourist, my motivation to speak the language of the place I am visiting is not solely self-serving – it is also inspired by a wish to be able to integrate into a locale, so that I am living there rather than just passing by, and invariably local inhabitants respond remarkably well to even the most over-excitable, and grammatically questionable, speakers of their mother tongue. In Bangladesh I wanted to resist the English speaker abroad stereotype, and was immediately thrown not only by the questionability of the assertion that English is the second language in Bangladesh (officially it is, but the competence and universality of such deviates enormously from country to country) but by my complete inability to either make myself understood or to understand the people around me without resorting to a mortifying mixture of signed actions (no, I don’t follow my logic here either) and facial muscle stretching.

Even in the London-based Bangladesh embassy I am ashamed to say that I had to resort to Google Translate to iterate my wish for them to relocate my passport and update me of the visa status. Safe to say I was put to the back of the queue (who am I kidding?!) and had to befriend (read: was taken pity on) a fellow travel applicant who was returning home to see his family over the Bangla New Year celebrations. With the entire world around me completely unrehearsed and unfamiliar, even non-verbal cues or fields of possible perception that might normally be derived from another persons’ accent, sartorial inclination or mannerisms are done away with when everything is plainly foreign.

As an avid people watcher, and constructer of improbable life narratives for strangers, I found this ignorance to social pointers frustrating on a personal level and potentially restrictive in the capacity of researcher. Asking people about their understandings of mental health, and indeed their experiences of it, cannot be plunged into blindly. While Lepra’s association had pre-established an element of trust and the information sheet and consent process soaked up any immediate practical questions, I found myself smiling inanely, nodding without knowing what I was agreeing with and generally looking so intently that I was probably just eyeballing everyone. The flipside to this potential weakness is that my total ignorance to any externally derived or verbal semiotic system avoided my interactions tipping into researcher prejudice or associative bias.

(L-R) Raha, me, Mr Shakhawat (TB Programme Officer) and Masud (office support officer and cook). Image Credit: A. Bow-Bertrand

(L-R) Raha, me, Mr Shakhawat (TB Programme Officer) and Masud (office support officer and cook). Image Credit: A. Bow-Bertrand

Perhaps this post is inspired by participant 10, or rather the reason for our having 31 rather than 30 interviewees as originally scheduled. Whether a selection error, or just incomplete patient details on the Lepra record sheets, this participant arrived, stooped over a self-fashioned wood crutch, with saliva pooling in his beard from a face half dropped from what I guess was a mild stroke. It was soon apparent that he was near wholly deaf, with his paralysis inhibiting all but the most restricted consonant sounds. The interview did not proceed as the others – the questionnaire was immediately disregarded as was any attempt to pursue the pre-defined topic guide.

The man was evidently desperate to make himself understood, clutching my hands and speaking in broken ejaculations. The majority of his narrative, or medical story perhaps, was relayed via the clinic staff in an assembly of dates, facts and diagnosis labels, all negating any reference to the psychological self that was so palpably in need of being explored and given room for in this interaction. Moving away from questions of suitability of the participant in relation to the selection criterion, it was painful to neither be able to make myself heard nor to be able to receive, verbatim, what he wished to say. I doubt he was fully aware that I neither spoke nor understood Bengali, but the complete lack of verbal offering and response afforded by the trajectory and closure of the normal research interview was an impossibility with participant 10. The session was considered closed once the clinic staff’s notes had dried up, and this was uncomfortably signaled to the participant with the monetary transaction or compensation for his travel costs, which in itself falsely pins ‘value’ to participant stories and their willingness to share.

Did I really understand anything about this individual? No. Could I sense and see his struggle? Absolutely. For felt communication is as essential to both verbal and visible communication and was something I took forward in the subsequent interviews. It is pertinent to close with this translated section from Closed Path by Bangladesh’s infamous poet Rabindranath Tagore whose language transcends national boundaries of geography and language, and continues to touch many: ‘and when old words die out on the tongue, new melodies break forth from the heart’.