The Gaddafi regime’s “last stand” mentality

Will the referral of Libya to the International Criminal Court backfire?

On 26 February, the UN Security Council passed a hard-hitting resolution designed to send a clear message to Muammar al-Gaddafi and his regime. As well as an asset freeze, travel ban and arms embargo, the UN took the unprecedented step of requesting that the International Criminal Court (ICC) investigate possible war crimes or crimes against humanity committed by Colonel Gaddafi and his forces.

Such a resolution might be expected to persuade most sane leaders to desist from extrajudicial killing, but Colonel Gaddafi is not your average leader. Several days on, it seems that not only did the message fail to stop the violence, but that it may be having the opposite effect, persuading members of the regime in Tripoli that they have no option other than to fight for their survival.

With the attention of the world focused on North Africa and the Middle East, the escalating violence in Libya presents a very public test of the international community's commitment to prevent crimes against humanity. With calls for international action becoming louder, the UN Security Council was stirred into action, passing a landmark resolution, the first of its kind to make unambiguous reference to the principle of "responsibility to protect".

In 2005, following its failures in Rwanda and Kosovo, the UN General assembly adopted the principle of "responsibility to protect", intended to provide a new level of international consensus that would allow swift action to prevent future atrocities. However, repeated failure to intervene in places such as Darfur, the Democratic Republic of Congo and Sri Lanka, combined with widespread post-Iraq cynicism toward all forms of so-called humanitarian intervention, suggested the principle might never be put into practice.

And then along came Libya.

While it was always unlikely that Gaddafi, who had already announced his intention to "fight until the last drop of blood", would be unduly bothered by a threat of referral to the ICC, it was hoped that members of his regime – most significantly the military – might take this loss of impunity more seriously. Indeed, Resolution 1970 allows for individuals thought to be responsible for attacks against civilians or human rights abuses to be nominated for addition to the ICC's charge sheet.

But, rather than encouraging the military to turn on Gaddafi, generals and soldiers who had already been involved in putting down the protests may well have been forced into the same "last stand" mentality as their leader.

This is not to say that Resolution 1970 was unwelcome, nor that the principle of responsibility to protect is unimportant. The international community should have an obligation to step in where states manifestly fail to protect their populations. The asset freeze and arms embargo will impact on Libya, but their effect will be slow and experience has shown that sanctions may cripple a nation without necessarily bringing down its governing regime.

Despite Robert Gates's description of it as "loose talk", contingency plans for some form of military intervention are no doubt being drawn up. The imposition of a no-fly zone would need to be authorised by the UN Security Council, and this is looking more possible following the recent shift in the French position and support from the Arab League. Whilst a no-fly zone would not prevent killing on the ground, it would stop aerial attacks by the Libyan air force and prevent weapons and other supplies from reaching Gaddafi's security forces.

The current situation in Libya remains turbulent and unclear. There are indications that a UN humanitarian team may be allowed into Tripoli, but in the meantime the violence continues. As each day passes and more blood soaks into the sand, the harder it will be for a post-conflict Libya to put itself together again. Bloody internal conflicts – be they in Iraq or Rwanda, Yugoslavia or Indonesia – leave indelible scars on nations and festering resentment among their populations.

The international community may struggle to find consensus as to the best way to prevent further bloodshed in Libya, but whatever action or inaction they choose, will be watched carefully by policymakers and dictators around the world. The success or failure of international action on Libya will no doubt shape future forms of humanitarian intervention and help determine how the principle of responsibility to protect can be put into practice.

Stefan Simanowitz is a journalist and Middle East/Africa analyst.

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British mental health is in crisis

The headlines about "parity of esteem" between mental and physical health remain just that, warns Benedict Cooper. 

I don’t need to look very far to find the little black marks on this government’s mental health record. Just down the road, in fact. A short bus journey away from my flat in Nottingham is the Queens Medical Centre, once the largest hospital in Europe, now an embattled giant.

Not only has the QMC’s formerly world-renowned dermatology service been reduced to a nub since private provider Circle took over – but that’s for another day – it has lost two whole mental health wards in the past year. Add this to the closure of two more wards on the other side of town at the City Hospital, the closure of the Enright Close rehabilitation centre in Newark, plus two more centres proposed for closure in the imminent future, and you’re left with a city already with half as many inpatient mental health beds as it had a year ago and some very concerned citizens.

Not that Nottingham is alone - anything but. Over 2,100 mental health beds had been closed in England between April 2011 and last summer. Everywhere you go there are wards being shuttered; patients are being forced to travel hundreds of miles to get treatment in wards often well over-capacity, incidents of violence against mental health workers is increasing, police officers are becoming de facto frontline mental health crisis teams, and cuts to community services’ budgets are piling the pressure on sufferers and staff alike.

It’s particularly twisted when you think back to solemn promises from on high to work towards “parity of esteem” for mental health – i.e. that it should be held in equal regard as, say, cancer in terms of seriousness and resources. But that’s becoming one of those useful hollow axioms somehow totally disconnected from reality.

NHS England boss Simon Stevens hails the plan of “injecting purchasing power into mental health services to support the move to parity of esteem”; Jeremy Hunt believes “nothing less than true parity of esteem must be our goal”; and in the House of Commons nearly 18 months ago David Cameron went as far as to say “In terms of whether mental health should have parity of esteem with other forms of health care, yes it should, and we have legislated to make that the case”. 

Odd then, that the president of the British Association of Counselling & Psychotherapy (BACP), Dr Michael Shooter, unveiling a major report, “Psychological therapies and parity of esteem: from commitment to reality” nine months later, should say that the gulf between mental and physical health treatment “must be urgently addressed”.  Could there be some disparity at work, between medical reality and government healthtalk?

One of the rhetorical justifications for closures is the fact that surveys show patients preferring to be treated at home, and that with proper early intervention pressure can be reduced on hospital beds. But with overall bed occupancy rates at their highest ever level and the average occupancy in acute admissions wards at 104 per cent - the RCP’s recommended rate is 85 per cent - somehow these ideas don’t seem as important as straight funding and capacity arguments.

Not to say the home-treatment, early-intervention arguments aren’t valid. Integrated community and hospital care has long been the goal, not least in mental health with its multifarious fragments. Indeed, former senior policy advisor at the Department of Health and founder of the Centre for Applied Research and Evaluation International Foundation (Careif) Dr Albert Persaud tells me as early as 2000 there were policies in place for bringing together the various crisis, home, hospital and community services, but much of that work is now unravelling.

“We were on the right path,” he says. “These are people with complex problems who need complex treatment and there were policies for what this should look like. We were creating a movement in mental health which was going to become as powerful as in cancer. We should be building on that now, not looking at what’s been cut”.

But looking at cuts is an unavoidable fact of life in 2015. After a peak of funding for Child and Adolescent Mental Health Service (CAMHS) in 2010, spending fell in real terms by £50 million in the first three years of the Coalition. And in July this year ITV News and children’s mental health charity YoungMinds revealed a total funding cut of £85 million from trusts’ and local authorities’ mental health budgets for children and teenagers since 2010 - a drop of £35 million last year alone. Is it just me, or given all this, and with 75 per cent of the trusts surveyed revealing they had frozen or cut their mental health budgets between 2013-14 and 2014-15, does Stevens’ talk of purchasing “power” sound like a bit of a sick joke?

Not least when you look at figures uncovered by Labour over the weekend, which show the trend is continuing in all areas of mental health. Responses from 130 CCGs revealed a fall in the average proportion of total budgets allocated to mental health, from 11 per cent last year to 10 per cent in 2015/16. Which might not sound a lot in austerity era Britain, but Dr Persaud says this is a major blow after five years of squeezed budgets. “A change of 1 per cent in mental health is big money,” he says. “We’re into the realms of having less staff and having whole services removed. The more you cut and the longer you cut for, the impact is that it will cost more to reinstate these services”.

Mohsin Khan, trainee psychiatrist and founding member of pressure group NHS Survival, says the disparity in funding is now of critical importance. He says: “As a psychiatrist, I've seen the pressures we face, for instance bed pressures or longer waits for children to be seen in clinic. 92 per cent of people with physical health problems receive the care they need - compared to only 36 per cent of those with mental health problems. Yet there are more people with mental health problems than with heart problems”.

The funding picture in NHS trusts is alarming enough. But it sits in yet a wider context: the drastic belt-tightening local authorities and by extension, community mental health services have endured and will continue to endure. And this certainly cannot be ignored: in its interim report this July, the Commission on acute adult psychiatric care in England cited cuts to community services and discharge delays as the number one debilitating factor in finding beds for mental health patients.

And last but not least, there’s the role of the DWP. First there’s what the Wellcome Trust describes as “humiliating and pointless” - and I’ll add, draconian - psychological conditioning on jobseekers, championed by Iain Duncan Smith, which Wellcome Trusts says far from helping people back to work in fact perpetuate “notions of psychological failure”. Not only have vulnerable people been humiliated into proving their mental health conditions in order to draw benefits, figures released earlier in the year, featured in a Radio 4 File on Four special, show that in the first quarter of 2014 out of 15,955 people sanctioned by the DWP, 9,851 had mental health problems – more than 100 a day. And the mental distress attached to the latest proposals - for a woman who has been raped to then potentially have to prove it at a Jobcentre - is almost too sinister to contemplate.

Precarious times to be mentally ill. I found a post on care feedback site Patient Opinion when I was researching this article, by the daughter of a man being moved on from a Mental Health Services for Older People (MHSOP) centre set for closure, who had no idea what was happening next. Under the ‘Initial feelings’ section she had clicked ‘angry, anxious, disappointed, isolated, let down and worried’. The usual reasons were given for the confusion. “Patients and carers tell us that they would prefer to stay at home rather than come into hospital”, the responder said at one point. After four months of this it fizzled out and the daughter, presumably, gave up. But her final post said it all.

“There is no future for my dad just a slow decline before our eyes. We are without doubt powerless – there is no closure just grief”.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.