Politics and Polio in Syria

Earlier this week Siddharth Chatterjee, Head of Strategic Partnerships at the International Federation of Red Cross and Red Crescent Societies, called for all sides to lay aside political considerations in the fight against the recent outbreak of polio in Syria. “When it comes to children’s health,” Chatterjee said, “you have to get the politics out of the way.”

It doesn’t sound like anyone’s listening. “The virus originates in Pakistan and has been brought to Syria by the jihadists who come from Pakistan”, the Syrian Minister of Social Affairs told reporters. The government has said it will vaccinate every child in Syria, including those in rebel-held areas, without explaining how this would be achieved or responding to international calls for a humanitarian ceasefire. Syrian activists, meanwhile, accused the government of blocking supplies of aid and medical equipment to rebel-held areas.

The imposition of politics on public health is nothing new. I’ve often been struck by the parallels between the Syrian and Spanish civil wars, and this story suggests obvious similarities to issues of war, health and politics under the Franco regime. Sadly, such parallels don’t suggest that Siddharth Chatterjee’s wish is going to come true any time soon.

As in the current conflict, disease was used for propaganda purposes both during and after the Civil War. Franco’s Director General of Health, José Palanca, claimed that spotted fever hadn’t occurred in Francoist areas before contact with enemy lines. The Civil War preceded the first European polio pandemics, but when the disease emerged in Spain in the early 1940s the regime initially refused to admit that an outbreak had taken place until it realised that it could use the association between polio and improved infant sanitary conditions to present it as a consequence of Spain’s economic and social development. On the opposing side, Republican authorities tried to restrict the activities of neutral international organisations such as Save the Children International for fear they’d be used as cover for the entry of nationalist spies.

Of course, this link between war, disease and politics goes a lot wider than the Spanish Civil War. Nazi Germany was obsessed with the wartime risk of a typhus outbreak spreading from Eastern Europe and put considerable effort into disinfection and quarantine programmes. Typhus, however, was seen in Germany at the time as a Jewish disease, and infection control was ultimately used as a metaphor, justification and a practical model for the mass murder of Jews.

In wartime, it seems, health and politics are difficult things to separate.

Sick of the government – the problem with state medical assessments

Government assessments of welfare claimants applying for Employment Support Allowance (ESA) and other disability benefits have come in for extensive criticism over the past few years. A recent blog post by Chris Barnes at the National Archives looking at medical appeals against conscription into the army in the First World War suggests that problems with state-run medical assessments are not a new phenomenon.

Chris’s research looked at over 400 records of men appealing against conscription into the armed forces on the grounds of ill health. The original medical examinations had been carried out by the military, but had been brought under civilian control in November 1917 after concerns at the number of men being unsuitably past fit for service by examiners under pressure to ensure an adequate supply of new troops. The examinations placed people into four categories from 1 (fit for service) to 4 (totally unfit for service).

Of the appeals examined Chris found that 50% had their grading lowered, and of the 54 cases reduced down to grade 4 it was revealed that a number had previously been discharged from the army on medical grounds. An excerpt from one of the appeals complains that the individual was seen by one doctor for less than five minutes, and that his responses were openly ridiculed. Chris also highlights the surprising number of cases that cite psychological issues such as depression, anxiety and ‘neurasthenia’ during a period where the stigma attached to “shirkers” and mental health issues in general was obviously very high.

Today’s Work Capability Assessments (WCA) were brought in under the last Labour government and have been extended under the coalition, and have come under widespread attack from the Public Accounts Committee, British Medical Association and Citizens Advice Bureau amongst others. Some of the similarities to the First World War medical assessments are striking.

Criticisms of the WCA have focussed on the structure of the test which grades people according to a points-based system.  Critics have argued that the assessments are often carried out by untrained or inattentive staff, are not sufficiently detailed, and are not able to accurately assess mental health or multiple conditions.

Almost 40% of those assessed as Fit to Work are currently having the decision overturned at appeal. Of these, the Citizens Advice Bureau says that over 60% received no points at all in their original assessment. Much of the controversy has focussed on the fact that the assessments are carried out by ATOS, a private company contracted by the government to run a range of health assessment and other services. Critics claim that the company puts assessors under pressure to declare as many claimants fit to work as possible.

What do these parallels tell us about state-run medical assessments?  It certainly highlights the difficulty in creating an assessment system to objectively rate and categorise the sick. Sickness and health is a complicated, messy affair, especially for those suffering from mental health or multiple health conditions, and these two cases seem to suggest an inherent tension between the desire of bureaucrats and politicians to place people into clearly defined “fit” and “well” boxes, and the reality of health as experienced by the individuals being assessed. It also suggests that governments can get into trouble where pressure, either real or perceived, is placed on medical assessors to categorise people a certain way.

The WCA process has been reviewed and changed a number of times since it was rolled out in response to some of these criticisms. It will be interesting to see if these ultimately appease its critics of whether the problems it faces are inherent to any form of state medical assessments.