A tense autumn to come in the Middle East

The international community must do everything possible to prevent further escalation across the region.

Across the Middle East, the Arab Uprisings of the last two years have given way to an atmosphere of continuous uncertainty and growing tension, in some areas marked by incidents of violence, sometimes prolonged, sometimes sporadic. The outlook in the months ahead is dark.

Darkest of all is the prolonged conflict in Syria. There are real fears that the intensifying battles there may spill over into other countries in the region. Turkey watches, deeply concerned. Together with Jordan, it is struggling with a huge influx of refugees from Syria. Protracted violence in Syria can only destabilise the region further and, the longer the factions war in Syria, the less likely it is that a single, unified and strong Government will succeed the morally bankrupt Assad regime.

Lakhdar Brahimi has impressed in his first days as UN envoy. But, as Kofi Annan discovered, the task in formulating a coherent international response to a growing crisis is immense. This is especially true within the UN Security Council. But we cannot allow the present position to continue: if we do so, the situation will worsen, not stay the same.

The particular danger is that conflict will spread beyond Syria's borders. Increased activity by Iran in emphasising its support for Assad has added to tension and violent incidents, such as that which happened in Turkey earlier this week, act as dangerous individual sparks in a flammable environment.

In Egypt, a similar, tense atmosphere prevails. President Morsi's dismissal  of individual members of the military establishment form part of a longer stand off between emerging democratic forces and a residually strong, but perhaps weakening, Army. The tide of Egyptian affairs appears to moving towards more openness but broad suspicion remains about the new Government's views on women's rights in the context of a new constitution. Concerns have been intensified by the recent violence in Sinai between the Egyptian forces and extremist elements, events which precipitated Morsi's personnel changes.

Israel had expressed concerns previously about extremist elements in Sinai, warning of increased instability there. It has added to Israel's increased anxiety at developments following the Arab Uprisings. Far from making Israel more amenable to dealing with Arab regimes with a more democratic mandate, events have caused Israel to be more concerned at trends in the region posing increased threats to its security. The perception is not helped by contacts between Hamas and the new Egyptian Government and also by intemperate language about Israel which, if stability is to prevail, must be recognised and accepted as a permanent, legitimate state in the region.

The next months, in the lead up to the US Presidential Election, are crucial. There has been strong concern expressed by Israel over many months over the lack of progress in securing Iran's compliance with its non-proliferation obligations. Rhetoric is intensifying once more and speculation of a pre-emptive military strike against Iran is increasing, not diminishing. It is a time for rational assessments and cool analysis. The impact of an attack at the heart of this, most sensitive and unpredictable of regions, is impossible to predict. The international community must take all steps it can to ensure that it does not take place.

Ian Lucas is the Labour MP for Wrexham

Protestors in Yemen in 2011. Photograph: Getty Images

Ian Lucas is the Labour MP for Wrexham.

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The surprising truth about ingrowing toenails (and other medical myths)

Medicine is littered with myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery.

From time to time, I remove patients’ ingrowing toenails. This is done to help – the condition can be intractably painful – but it would be barbaric were it not for anaesthesia. A toe or finger can be rendered completely numb by a ring block – local anaesthetic injected either side of the base of the digit, knocking out the nerves that supply sensation.

The local anaesthetic I use for most surgical procedures is ready-mixed with adrenalin, which constricts the arteries and thereby reduces bleeding in the surgical field, but ever since medical school I’ve had it drummed into me that using adrenalin is a complete no-no when it comes to ring blocks. The adrenalin cuts off the blood supply to the end of the digit (so the story goes), resulting in tissue death and gangrene.

So, before performing any ring block, my practice nurse and I go through an elaborate double-check procedure to ensure that the injection I’m about to use is “plain” local anaesthetic with no adrenalin. This same ritual is observed in hospitals and doctors’ surgeries around the world.

So, imagine my surprise to learn recently that this is a myth. The idea dates back at least a century, to when doctors frequently found digits turning gangrenous after ring blocks. The obvious conclusion – that artery-constricting adrenalin was responsible – dictates practice to this day. In recent years, however, the dogma has been questioned. The effect of adrenalin is partial and short-lived; could it really be causing such catastrophic outcomes?

Retrospective studies of digital gangrene after ring block identified that adrenalin was actually used in less than half of the cases. Rather, other factors, including the drastic measures employed to try to prevent infection in the pre-antibiotic era, seem likely to have been the culprits. Emboldened by these findings, surgeons in America undertook cautious trials to investigate using adrenalin in ring blocks. They found that it caused no tissue damage, and made surgery technically easier.

Those trials date back 15 years yet they’ve only just filtered through, which illustrates how long it takes for new thinking to become disseminated. So far, a few doctors, mainly those in the field of plastic surgery, have changed their practice, but most of us continue to eschew adrenalin.

Medicine is littered with such myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery. Until the mid-1970s, breast cancer was routinely treated with radical mastectomy, a disfiguring operation that removed huge quantities of tissue, in the belief that this produced the greatest chance of cure. These days, we know that conservative surgery is at least as effective, and causes far less psychological trauma. Seizures can happen in young children with feverish illnesses, so for decades we placed great emphasis on keeping the patient’s temperature down. We now know that controlling fever makes no difference: the fits are caused by other chemicals released during an infection.

Myths arise when something appears to make sense according to the best understanding we have at the time. In all cases, practice has run far ahead of objective, repeatable science. It is only years after a myth has taken hold that scientific evaluation shows us to have charged off down a blind alley.

Myths are powerful and hard to uproot, even once the science is established. I operated on a toenail just the other week and still baulked at using adrenalin – partly my own superstition, and partly to save my practice nurse from a heart attack. What would it have been like as a pioneering surgeon in the 1970s, treating breast cancer with a simple lumpectomy while most of your colleagues believed you were being reckless with your patients’ future health? Decades of dire warnings create a hefty weight to overturn.

Only once a good proportion of the medical herd has changed course do most of us feel confident to follow suit. 

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

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