World Mental Health Day: in times of crisis

The importance of raising awareness of mental health, or mental ill health, is ever relevant. Today, Anna Freud National Centre for Children and Families, where I am Press Officer, joined the Heads Together campaign of which we are a partner charity, in marking World Mental Health Day. One of the key aims of the day was to recognise that all of us will experience a traumatic event or transitional period at some point in our lives, and be that involvement in a car accident; exposure to persistent bullying; or a specific mental health crisis, emotional fall-out is often to be expected. With such an expectation comes an opportunity to share how we can be supported through difficult times. Through such distress, psychological support from each other, as well as from professionals, can be invaluable sources of care-giving and therapy.

We supported an event held at the riverside County Hall and the London Eye, attended by Their Royal Highnesses the Duke and Duchess of Cambridge and Prince Harry who met guests with stories of crisis and their supporting cast of friends, family, and education and clinical professionals who have played a role in helping them through these difficult times. Since starting in this role, such involvement with the Heads Together campaign has created a demanding but brilliant opportunity to rapidly implement and develop press skills and promote awareness for psychological wellbeing in a way that carries integrity to the real experiences of those showcased or helped through the work of the Centre.

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Of course, working in London, for a national charity, it can be easy to forget that this day is celebrated globally and, further, that such commitment to supporting one another and normalising the conversation on mental health must be a continuous endeavour, rather than the perceived efforts of a single day. With this in mind, and having recently submitted my Masters dissertation looking at the psychosocial impacts on persons affected by leprosy (PAL), it seems as good a time as any to highlight, again, the work of Lepra, the organisation who hosted me so brilliantly in Bangladesh during my primary data collection research in the Sirajganj district. In an article published on their website today, they cited preliminary findings from this research  which set out to: 1) Assess the psychosocial impact of leprosy-related disability by employing mixed methods 2) Determine what is understood by ‘psychological’ and ‘mental health’ among this population and  3) Explore perceptions of leprosy at both personal and policy-levels, and its relation to mental health.

Key messages from this exploration into mental health initially highlight that:

  • Lack of education around leprosy is the primary reason for delayed presentation to appropriate medical services.
  • Within this context, leprosy-related disability is figured solely in physical terms classified under medical frames of reference.
  • ‘Alienation’ conceptualises the life experience of the PAL in this study, influenced by trauma, mental and physical disability, and lack of explanatory theoretical frameworks.
  • Following education, economic seed projects were identified as a sustainable, acceptable intervention to tackle the psychosocial impact of leprosy-related disability on past and future PAL in this region by promoting social integration and financial self-sufficiency.

What these findings show is that education of mental health is critical, acknowledging that it needs regular ‘checks’ and appropriate response to challenges i.e. that parity between physical and psychological health must be prioritised and remain a focus for us all.

 

Image Credits (all): A.Bow-Bertrand

Header image: Felix E. Guerrero, Flicke

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

Photojournalist of the month: Jiro Ose

Hailing from Osaka, Japan, Jiro Ose has worked as a freelance photojournalist since 2005, and has covered the historical election in Congo, the Sudanese refugee crisis and the departure of deposed president Jean-Bertrand Aristide in Haiti amongst other events and states. His coverage of the Democratic Republic of Congo election won him the Award of Excellence in the Magazine General News Story category of the Pictures of the Year International competition . The selection below are drawn from Ose’s ‘SOS from Iraq’ which he describes as follows:

I was sent to cover the 2003 Invasion of Iraq by Newsday, one of New York’s dailies. I entered Northern Iraq (Kurdistan) through Iran, like many other journalists who were rushed in to cover the war. When the City of Kirkuk fell, I entered with Kurdish Peshmaga fighters and thousands thronged the streets and greeted us as though we were liberators of the city. Saddam was finally gone. The air was filled with euphoria. People danced and chanted on the street. A bronze statue of Saddam was brought down and beaten with their sandals.

I hardly saw any fighting except American bombers dropping bombs on Kirkuk in the distance. Infamous Republican Guards peeled off their uniforms and melted into the population. It was dangerous, still. It was still a war. I walked the field where another journalist was killed by stepping on a landmine. I drove past the intersection where, only half an hour later, another journalist was killed when a suicide bomber drove through in a car laden with explosives. What was to come there after is beyond comparison: the total collapse of Iraqi society, fighting between religious and ethnic lines. Yet, the only time I saw the dark sign of what was to come was the second night in Kirkuk.

I heard a lot of commotion outside the hotel. Parked in front was a taxi. On its bonnet lay a boy’s lifeless body. Half of his head was blown clean off. A group of men who had surrounded the taxi were shouting; these were Turkmen, one of the many minority groups in Iraq. They said they were under attack by Kurds, and that the boy was shot by a Kurdish sniper. They knew that a group of international journalists were staying at the hotel. The protest lasted about an hour and when the men left the lifeless body on the ground remained. Several hours later, someone could no longer tolerate its sight, so covered it with a flag of Turkmen.

Yet, I still did not really seen the real cost of the war, if you call it a war, until I visited Red Crescent Hospital in Amman, Jordan 5 years later.

Walking through the 2nd floor of Red Crescent hospital in Amman, Jordan, you bear witness to the devastation the war and ensuing violence have brought upon the civilian population on a daily basis in Iraq. Because of the curfew, lack of safety and medical supplies, hospitals inside Iraq cannot perform long and complicated surgery. They are the lucky ones (referring to a selected few who are brought to the hospital to the program by Medecins Sans Frontiers , MSF, France),” said Dr. Nasser, an Iraqi plastic surgeon who preferred that only his first name to be used. Because of the escalating violence, MSF France pulled their international staff from Iraq three years ago. Now they assist Iraqi hospitals across the border by providing drugs and medical supplies. They also set up a surgical program in cooperation with the Jordanian Red Crescent Hospital in Amman where they perform reconstructive surgery for patients who have been handicapped by injuries or incomplete procedures free of charge, including transportation from Iraq and back after the recovery. 

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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:

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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).

Preach.

Preach.


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…

 

Bibliography

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: <https://analepsis.files.wordpress.com/2013/08/hall-west-the-rest.pdf&gt; [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:

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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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Appendix

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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: https://www.cambridge.gov.uk/the-single-homelessness-service [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: http://www.cambridgecyrenians.org.uk/index.php/accomodation-service [Accessed 9 May 2016]

Cambridge Past, Present & Future (2014) Possible Brownfield Sites within the Urban Area of Cambridge [online]. Cambridge. Available from: http://www.cambridgeppf.org/submissions/possible-brownfield-sites-within-the-urban-area-of-cambridge/ [Accessed 6 May 2016]

Cambridge Past, Present & Future (2016) Planning and Heritage [online]. Cambridge. Available from: http://www.cambridgeppf.org/planning/ [Accessed 12 May 2016]

Cambridge Streetbite (2015) Cambridge Streetbite Society. Cambridge. Available from: http://streetbite.soc.srcf.net [Accessed 9 May 2016]

Cambridgeshire Insight (2016) Population forecasts. Cambridge. Available from: http://www.cambridgeshireinsight.org.uk/population-and-demographics/population-forecasts [Accessed 10 May 2016]

CamShare (2002) CamShare: Car Share, Cycle Share, CamShare. Cambridge. Available from: https://camshare.liftshare.com [Accessed 28 April 2016]

Centre for Cities (2016) Cities Outlook [online]. London. Available from: http://www.centreforcities.org/wp-content/uploads/2016/01/Cities-Outlook-2016.pdf [Accessed 10 May 2016]

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: http://cambridgeppf.org/vision/ [Accessed 10 May 2016]

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O’Brien, L et al. (2010) Urban health and health inequalities and the role of urban forestry in Britain: a review [online]. Melbourne. Available from: http://www.forestry.gov.uk/pdf/urban_health_and_forestry_review_2010.pdf/$FILE/urban_health_and_forestry_review_2010.pdf [Accessed 12 May 2016]

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

Rydin, Y et al. (2012) Shaping cities for health: complexity and planning of urban environments in the 21st century. The Lancet [online], 6736(12) pp 1-30 https://www.ucl.ac.uk/healthy-cities/outputs/lancet [Accessed 10 May 2016]

Salvesen, C (1965) The Landscape of Memory: A Study of Wordsworth’s Poetry. London: Edward Arnold

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Till, A (1994) The Collected Poems of William Wordsworth. Hertfordshire: Wordsworth Poetry Library

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Van Cauwenberg, V. et al. (2014) Physical Environmental Factors that invite older adults to walk for transportation. Journal of Environmental Psychology 38 (12) pp 94-103.

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Wilson L. et al (2013) Enhancing the Climate Change Benefits of Urban Trees in Cambridge [online]. Cambridge. Available from: ‪http://www.charteredforesters.org/resources/download-library/doc_download/316-hockridge-et-al-enhancing-the-climate-change-benefits-of-urban-trees-in-cambridge/‪ [Accessed 1 May 2016]

Wyatt, J (1995) Wordsworth and the Geologists. New York: Cambridge University Press

Image Credits:

Footer panorama: The River Cam. KBJX6, 2015.

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

MdM Reads of the Month

Every month MdM recommends an anthology or monograph for readerly perusal. Inevitably, these suggestions spark discussion both on and off-screen, including a recent request for a showcase of the other global health blogs (and vlogs) that  I return to again and again.

The below is a wild but wonderful selection of my most tried and tested reads as well as some more recent discoveries, to which I am always delighted to add. Please comment below if there are others we should know about.

 

This Week in Global Health (TWIGH)

Dr. Martin has achieved cult status amongst student global healthers for his brand of accessible, bitesize updates on careers, policy and research each week. While this is all published on his blog , his YouTube channel is really worth following. Offering a platform for entry-level professionals across NGOs and PPPs, his vlogs also feature charmingly dodgy web-cam use from his token resident global health elder, Terry Schmidt. Would recommend plugging in your sound and skipping the visuals or just heading straight to the podcast playlist.

 

Prospect Journal

Categorised by part of the world, this online journal showcases the writings of University of California (SD) students of international affairs. With a considered scientific angle, the editor’s blog explores contemporary issues making national news. Many of the blog titles err towards clickbait, but looking beyond the excessive use of the rhetorical question the content invariably represents a skilful distillation of complex issues such as climate change into academic yet accessible reads.

 

Polygeia

Admittedly, I spent a lot of my spare time at university as Press Officer and Blog Editor for this think tank, but the content is noteworthy for its breadth and tangible policy implications. Spanning topics and commissions as diverse as Action Against Hunger to leprosy missions with Lepra, the blogs track the progress of policy work for external organisations generally over 12-month periods, drawing on the most current comment and research in their respective focal sectors.

 

National Public Radio (NPR): Goats and Soda

Less traditional blog, more broadcaster with accompanying transcripts, NPR’s ‘Goats and Soda’ publishes stories from a changing world with a prioritisation of health and development concerns. As a starting point, I would recommend reading their blog that details how the name ‘Goats and Soda’ came about. There is a lightness of touch in all of their work as well as great visuals and some outstanding interview pieces. Not always topical, but a constant source of inspiration.

 

Global Health NOW

Perhaps slightly biased given that I was fortunate enough to be commended for my suggestion of an untold global health story in their recent competition, for which the I wrote an article on the overlooked killer, Kala Azar (available here), but with due credit: Global Health NOW is an initiative from the John Hopkins Bloomberg School of Public Health. One of the most prolific of all these recommendations, GHN staff scour the daily news, reports and published research for the most interesting reads, compiling these into their e-newsletter which is disseminated along with social media coverage. A favourite for spotting new writing and noteworthy topics.

 

LinkedIn groups: Global Public Health

LinkedIn’s largest public health group, GPH is for those working professionally or studying areas of international public health importance, with a focus on health issues impacting low- and middle-income countries. One of the benefits of joining such a group is that discussion is often more lively and instantaneous than on blogging sites. Forums associated with these groups facilitate a blog conversation that extends beyond the confines of the written piece.

 

The Lancet Global Health Blog

The Lancet Global Health journal is a comprehensive periodic read, but the tangential blog platform is worth dipping into. Guest and regular writers cover a host of topics from access to medicines, blood donations, urbanisation and collectively take a macro look at challenges within the field and consider possible answers to these.

 

GH on the Guardian 

Sadly this series finished last year, but thankfully the blogs have yet to be archived. Sarah Boseley is a magical writer, making the unfathomable feintly outlined and the tragic compelling rather than hopeless. Described as ‘The Guardian’s health editor on the politics, policies, philanthropy and progress being made in the fields of global health and aid‘, you can look back through titles that consider the policies and politics of Pharma, the hidden costs of healthcare in conflict zones and commentaries that consistently explore issues from every angle.

 

Comment below with your own must-reads.

 

Image Credit: A. Bow-Bertrand

Urban Health and the Built Environment

On a grey February evening, the lure of complimentary wine and cheese, and a great track record of talks was enough to find me at the University of Westminster’s Fyvie Hall. There, James Wates, CEO and Chairman of the Princes’ Trust Built Environment Leadership Group and Vice Chair of the Queen Elizabeth’s Foundation for Disabled People was presenting ‘Why Professionalism is as important to the built environment as it is to medicine‘.

Image Credit: A Bow-Bertrand

Made it. Image Credit: A Bow-Bertrand

You may be wondering how there can be crossovers or comparisons drawn between the construction industry and the field of medicine. But both fundamentally prioritise quality of care and safeguarding of human welfare. Indeed, Wates drew on our immediate situation, highlighting that it was essential for us to have cover and warmth in order for the talk to proceed. So too, in order to survive, we need buildings in the form of schools and hospitals, shelter in the form of a roof on our homes and functional infrastructure to provide sustainable supplies of potable water.

Wates then cited the comparable need for teamwork between the two sectors using John Godfrey Saxe’s 1878 analogy (by way of Indian parable) of five blindfolded builders touching an elephant (one touched the trunk and thought he was dealing with a hosepipe; another a leg and thought it was a tree, another the tail and surmised it was a rope, yet another the body of the beast and thought it was a wall, and finally another touched the tusk and thought it was a sewer). Only through communication, cooperation and prioritisation of what Wates called ‘professionalism’ could the safety and suitability of the finished product (which he related to the medical ‘patient’ or bodily construct) be ensured.

Image Credit: A Bow-Bertrand

Making Introductions. Image Credit: A Bow-Bertrand

Where mistakes are made on a construction project, they are, according to Wates, frequently irreversible as is the case in much of medicine in which: ‘good patient care turns into misery and despair; for the built environment projects that turn bad can damage so much. The advantage the built environment professional has is scale; we do big things that can last for generations’. To me, it is problematic to suggest that professionalism is of comparable importance to the building industry as to medicine. Or, rather not that it isn’t important but to question whether they are even synonymous.

Indeed, medicine, unlike construction, is a profession in the vocational sense. So to consider professionalism as a quality of it is to overlook the very composite quality of this field. The two are not comparable, and can only be contrasted to a certain extent. Certainly, I agree with Wates’ comment that ‘the built environment and medicine have a lot in common. Each have a number of different specialisms which seek to address particular issues. When it works it all goes well, when it doesn’t then there are major problems and we end up losing focus on what we are trying to achieve’.

However, in spite of the caveats, there is real interest in this field in terms of medicine and global health, most particularly in how the built environment can impact user and client wellbeing. We have all read reports of office  workers who sit near to a window who sleep better at night and those who report greater work satisfaction if there is sufficient communal space within their workplace. This is one facet addressed by and in the area of urban health, but which demands a discourse of management rather than ‘professionalism’.

 

Image Credit: A. Bow-Bertrand

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).

 

Bibliography

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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].

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

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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